Provider Demographics
NPI:1780706663
Name:NALLUR, SHIVA (MD)
Entity type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:NALLUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10301 KANIS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6205
Mailing Address - Country:US
Mailing Address - Phone:501-562-4838
Mailing Address - Fax:501-562-1958
Practice Address - Street 1:10301 KANIS RD STE 1
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6205
Practice Address - Country:US
Practice Address - Phone:501-562-4838
Practice Address - Fax:501-562-1958
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE5407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174913001Medicaid
AR57297Medicare PIN
AR174913001Medicaid