Healthcare Provider Details

I. General information

NPI: 1033193891
Provider Name (Legal Business Name): SHIVAKUMAR VIGNESH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 E BANNER GATEWAY DR., SUITE 400
GILBERT AZ
85234
US

IV. Provider business mailing address

2946 E BANNER GATEWAY DR., SUITE 400
GILBERT AZ
85234
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-3332
  • Fax: 813-449-8028
Mailing address:
  • Phone: 480-256-3332
  • Fax: 813-449-8028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number040551
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME102765
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number64480
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: