Provider Demographics
NPI:1659702819
Name:NALLAM, SIVA PAVANI (MD)
Entity Type:Individual
Prefix:DR
First Name:SIVA PAVANI
Middle Name:
Last Name:NALLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SIVA PAVANI
Other - Middle Name:
Other - Last Name:PUPPALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2349 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5505
Mailing Address - Country:US
Mailing Address - Phone:630-877-7629
Mailing Address - Fax:
Practice Address - Street 1:2349 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5505
Practice Address - Country:US
Practice Address - Phone:209-469-2229
Practice Address - Fax:209-466-2436
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA161250208000000X
390200000X
PAMD462023208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program