Provider Demographics
NPI:1558517680
Name:SHIVARAM, GIRIDHAR MYSORE (MD)
Entity Type:Individual
Prefix:DR
First Name:GIRIDHAR
Middle Name:MYSORE
Last Name:SHIVARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GIRI
Other - Middle Name:
Other - Last Name:SHIVARAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:M/S MA.7.220, PO BOX 5371
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:206-987-2166
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-08
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD601802672085R0202X, 2085R0204X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA371560Medicare UPIN