Provider Demographics
NPI:1932321981
Name:CHAMPANERI, SHIVAM A (MD)
Entity Type:Individual
Prefix:
First Name:SHIVAM
Middle Name:A
Last Name:CHAMPANERI
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 1:6354 WALKER LN STE 400
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3252
Mailing Address - Country:US
Mailing Address - Phone:571-472-7322
Mailing Address - Fax:571-472-7323
Practice Address - Street 1:6354 WALKER LN STE 400
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3252
Practice Address - Country:US
Practice Address - Phone:571-472-7322
Practice Address - Fax:571-472-7323
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101253867207R00000X, 207RE0101X
MDD0072073207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD043171100Medicaid
MD219413ZD2XMedicare PIN
MD157676Medicare PIN