Provider Demographics
NPI:1790779841
Name:RAO, SHIVA KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:KUMAR
Last Name:RAO
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 1:511 HOLLY RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-2270
Mailing Address - Country:US
Mailing Address - Phone:252-537-2254
Mailing Address - Fax:
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1117
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975961Medicaid
NC8975961Medicaid
NC2207993Medicare PIN