Provider Demographics
NPI:1821018730
Name:SHIVARAM, VIDYULLATHA (MD)
Entity Type:Individual
Prefix:
First Name:VIDYULLATHA
Middle Name:
Last Name:SHIVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25892 N JAMES MADISON HWY
Mailing Address - Street 2:PO BOX 220
Mailing Address - City:NEW CANTON
Mailing Address - State:VA
Mailing Address - Zip Code:23123-0220
Mailing Address - Country:US
Mailing Address - Phone:434-581-3271
Mailing Address - Fax:434-581-1105
Practice Address - Street 1:25892 N JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:NEW CANTON
Practice Address - State:VA
Practice Address - Zip Code:23123-0220
Practice Address - Country:US
Practice Address - Phone:434-581-3271
Practice Address - Fax:434-581-1105
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054431174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30890Medicare UPIN