Provider Demographics
NPI:1497844112
Name:SUDHAKAR, SIVARAM (MD)
Entity Type:Individual
Prefix:MR
First Name:SIVARAM
Middle Name:
Last Name:SUDHAKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MEDI PARK
Mailing Address - Street 2:SUITE # 1062
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106
Mailing Address - Country:US
Mailing Address - Phone:806-463-1652
Mailing Address - Fax:806-463-1736
Practice Address - Street 1:1901 MEDI PARK
Practice Address - Street 2:SUITE # 1062
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-463-1652
Practice Address - Fax:806-463-1736
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH78362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH7836OtherSTATE LICENSE
TX130454506Medicaid
TX130454506Medicaid