Provider Demographics
NPI:1750385373
Name:SIVAMURTHY, SHETRA (MD)
Entity type:Individual
Prefix:
First Name:SHETRA
Middle Name:
Last Name:SIVAMURTHY
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 1:8934 134TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2819
Mailing Address - Country:US
Mailing Address - Phone:718-526-3899
Mailing Address - Fax:718-526-3233
Practice Address - Street 1:8934 134TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2819
Practice Address - Country:US
Practice Address - Phone:718-526-3899
Practice Address - Fax:718-526-3233
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2011-10-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
NY111600207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY111600OtherNYS LICENSE NUMBER
NYB17231Medicare UPIN
NY111600OtherNYS LICENSE NUMBER