Provider Demographics
NPI:1588655450
Name:SHIVARAM, DEEPAK A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:A
Last Name:SHIVARAM
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 1:44215 15TH ST W
Mailing Address - Street 2:STE. 111
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-4014
Mailing Address - Country:US
Mailing Address - Phone:661-949-5941
Mailing Address - Fax:661-949-5871
Practice Address - Street 1:44215 15TH ST W STE 111
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-5503
Practice Address - Country:US
Practice Address - Phone:661-949-5941
Practice Address - Fax:661-949-5871
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A621770Medicaid
CA331042573OtherTAX ID#
CAA62177Medicare ID - Type Unspecified
CAG62688Medicare UPIN