Provider Demographics
NPI:1982756565
Name:MUDALI, SHIYAMA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIYAMA
Middle Name:
Last Name:MUDALI
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 1:7111 FAIRWAY DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4204
Mailing Address - Country:US
Mailing Address - Phone:800-330-6565
Mailing Address - Fax:561-712-7349
Practice Address - Street 1:375 DIXMYTH AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-865-1321
Practice Address - Fax:513-865-1254
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120826207ZH0000X
FLME108420207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003496200Medicaid
FLFB529ZMedicare PIN