Provider Demographics
NPI:1821035254
Name:SIVAKUMAR, KUMARASWAMY (MD)
Entity type:Individual
Prefix:DR
First Name:KUMARASWAMY
Middle Name:
Last Name:SIVAKUMAR
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 1:4545 E SHEA BLVD
Mailing Address - Street 2:STE 175
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3074
Mailing Address - Country:US
Mailing Address - Phone:480-314-1007
Mailing Address - Fax:480-314-1003
Practice Address - Street 1:4545 E SHEA BLVD
Practice Address - Street 2:STE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3074
Practice Address - Country:US
Practice Address - Phone:480-314-1007
Practice Address - Fax:480-314-1003
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25540174400000X, 2084N0400X, 2084N0600X, 261QI0500X, 2084N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No174400000XOther Service ProvidersSpecialist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ393108Medicaid
AZZ64912Medicare PIN
AZ393108Medicaid