Provider Demographics
NPI:1649694126
Name:SIVARUBAN, PREMINI (MD)
Entity type:Individual
Prefix:
First Name:PREMINI
Middle Name:
Last Name:SIVARUBAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PREMINI
Other - Middle Name:
Other - Last Name:SELVARAJAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5559
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:11333 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1116
Practice Address - Country:US
Practice Address - Phone:818-365-9531
Practice Address - Fax:818-837-5741
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130018208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1300180Medicaid
CA00A1300180Medicaid