Provider Demographics
NPI:1942393566
Name:SHIVARAM, SUNIL M (MD)
Entity Type:Individual
Prefix:
First Name:SUNIL
Middle Name:M
Last Name:SHIVARAM
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 1:655 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711
Mailing Address - Country:US
Mailing Address - Phone:909-624-8077
Mailing Address - Fax:909-624-1467
Practice Address - Street 1:655 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711
Practice Address - Country:US
Practice Address - Phone:909-624-8077
Practice Address - Fax:909-624-1467
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62267207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A622670Medicaid
CA1438533Medicaid
CAA62267Medicare PIN
CAH23801Medicare UPIN