Provider Demographics
NPI:1831683739
Name:SIVARAM, GHOMATHY (MD)
Entity type:Individual
Prefix:DR
First Name:GHOMATHY
Middle Name:
Last Name:SIVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 SUFFOLK DOWNS
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-5817
Mailing Address - Country:US
Mailing Address - Phone:330-389-4210
Mailing Address - Fax:
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-389-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042961207Q00000X
OH57.253417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine