Healthcare Provider Details

I. General information

NPI: 1871908871
Provider Name (Legal Business Name): VEERESH KUMAR NANJANGUD SHIVAMURTHY M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ASYLUM AVE STE 2112
HARTFORD CT
06105-1719
US

IV. Provider business mailing address

1000 ASYLUM AVE STE 4304
HARTFORD CT
06105-1704
US

V. Phone/Fax

Practice location:
  • Phone: 860-522-3711
  • Fax: 860-493-1885
Mailing address:
  • Phone: 860-522-3711
  • Fax: 860-493-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number64218
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number64218
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code273100000X
TaxonomyEpilepsy Hospital Unit
License Number64218
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number64218
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: