Provider Demographics
NPI:1972773950
Name:SHIVAKUMAR, ASHWIN BALLUPET (MD MS)
Entity Type:Individual
Prefix:
First Name:ASHWIN
Middle Name:BALLUPET
Last Name:SHIVAKUMAR
Suffix:
Gender:M
Credentials:MD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FORUM LL
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-3110
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:FORUM LL
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine