Healthcare Provider Details

I. General information

NPI: 1912644071
Provider Name (Legal Business Name): SOWMYA SIVAKUMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 ROGERS AVE
FORT SMITH AR
72903-4100
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-6245
  • Fax: 479-452-0275
Mailing address:
  • Phone: 479-314-6245
  • Fax: 479-452-0275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE19585
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number27641
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: