Provider Demographics
NPI:1528199023
Name:TIVAKARAN, SANJEEVI C (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEVI
Middle Name:C
Last Name:TIVAKARAN
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 1:2400 HOSPITAL DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2385
Mailing Address - Country:US
Mailing Address - Phone:318-752-7840
Mailing Address - Fax:318-752-7845
Practice Address - Street 1:2400 HOSPITAL DR
Practice Address - Street 2:SUITE 220
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2385
Practice Address - Country:US
Practice Address - Phone:318-752-7840
Practice Address - Fax:318-752-7845
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11838R2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5H637Medicare PIN
G10471Medicare UPIN