Provider Demographics
NPI:1932328747
Name:SIVAGNANAM, MAMATA (MD)
Entity Type:Individual
Prefix:
First Name:MAMATA
Middle Name:
Last Name:SIVAGNANAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAMATA
Other - Middle Name:
Other - Last Name:ENGINEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE #210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4802
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:8110 BIRMINGHAM WAY
Practice Address - Street 2:BLDG 28
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2758
Practice Address - Country:US
Practice Address - Phone:858-966-4003
Practice Address - Fax:858-560-6798
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA868632080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology