Provider Demographics
NPI:1972915544
Name:ANNAMALAI, SHIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:ANNAMALAI
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 1:96 CAMPUS DR STE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7164
Mailing Address - Country:US
Mailing Address - Phone:207-885-9905
Mailing Address - Fax:
Practice Address - Street 1:96 CAMPUS DR STE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7164
Practice Address - Country:US
Practice Address - Phone:207-885-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD24429207RC0000X
NH21201207RC0000X
MA259538207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty