Provider Demographics
NPI:1255750980
Name:MUDEGOWDRA, NIVEDITHA SHIVAKUMAR
Entity type:Individual
Prefix:
First Name:NIVEDITHA
Middle Name:SHIVAKUMAR
Last Name:MUDEGOWDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31244 COUNTRY WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1041
Mailing Address - Country:US
Mailing Address - Phone:248-661-1262
Mailing Address - Fax:
Practice Address - Street 1:805 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:269-286-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105276207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine