Provider Demographics
NPI:1558493874
Name:PANCHAMOORTHY, SIVA (RD)
Entity Type:Individual
Prefix:
First Name:SIVA
Middle Name:
Last Name:PANCHAMOORTHY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 WORSTER DR
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-5004
Mailing Address - Country:US
Mailing Address - Phone:508-251-1671
Mailing Address - Fax:
Practice Address - Street 1:59 TOWNSEND ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1318
Practice Address - Country:US
Practice Address - Phone:617-989-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1469133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered