Provider Demographics
NPI:1750675609
Name:SIVAKUMAR, NIRANJAN (MD)
Entity Type:Individual
Prefix:
First Name:NIRANJAN
Middle Name:
Last Name:SIVAKUMAR
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 1:3525 ENSIGN RD NE
Mailing Address - Street 2:SUITE K
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5065
Mailing Address - Country:US
Mailing Address - Phone:360-413-8121
Mailing Address - Fax:
Practice Address - Street 1:3525 ENSIGN RD NE
Practice Address - Street 2:SUITE K
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5065
Practice Address - Country:US
Practice Address - Phone:360-413-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60661919207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2059291Medicaid