Healthcare Provider Details

I. General information

NPI: 1821035254
Provider Name (Legal Business Name): KUMARASWAMY SIVAKUMAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E SHEA BLVD STE 175
PHOENIX AZ
85028-3074
US

IV. Provider business mailing address

4545 E SHEA BLVD STE 175
PHOENIX AZ
85028-3074
US

V. Phone/Fax

Practice location:
  • Phone: 480-314-1007
  • Fax: 480-314-1003
Mailing address:
  • Phone: 480-314-1007
  • Fax: 480-314-1003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25540
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25540
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number25540
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number25540
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number25540
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: