Provider Demographics
NPI:1811332174
Name:SIVAGANESAN, AHILAN
Entity type:Individual
Prefix:
First Name:AHILAN
Middle Name:
Last Name:SIVAGANESAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 CREEKSIDE BLVD E UNIT 102
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0595
Mailing Address - Country:US
Mailing Address - Phone:239-624-1700
Mailing Address - Fax:
Practice Address - Street 1:1285 CREEKSIDE BLVD E UNIT 102
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0595
Practice Address - Country:US
Practice Address - Phone:239-624-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME168845207T00000X
PAMD474192207T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123078700Medicaid
FLGAGZNOtherBCBS