Provider Demographics
NPI:1760665665
Name:SIVAKAMI K SIVAPALAN MD, INC
Entity Type:Organization
Organization Name:SIVAKAMI K SIVAPALAN MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIVAKAMI
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIVAPALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-808-8627
Mailing Address - Street 1:1824 LUCY LN
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-8612
Mailing Address - Country:US
Mailing Address - Phone:951-808-8627
Mailing Address - Fax:
Practice Address - Street 1:1824 LUCY LN
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-8612
Practice Address - Country:US
Practice Address - Phone:951-808-8627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64125208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641250Medicaid
CA00A641254Medicare PIN