Provider Demographics
NPI:1639208218
Name:SIVA, SUBRAMANIAM - (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBRAMANIAM
Middle Name:-
Last Name:SIVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SUBRAMANIAM
Other - Middle Name:-
Other - Last Name:SIVALOGANATHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1461 SOUTH BRITAIN ROAD
Mailing Address - Street 2:SOUTHBURY TRAINING SCHOOL
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-0901
Mailing Address - Country:US
Mailing Address - Phone:203-586-2503
Mailing Address - Fax:203-586-2701
Practice Address - Street 1:1461 SOUTH BRITAIN ROAD
Practice Address - Street 2:SOUTHBURY TRAINING SCHOOL
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-0901
Practice Address - Country:US
Practice Address - Phone:203-586-2503
Practice Address - Fax:203-586-2701
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018565207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD32587Medicare UPIN