Healthcare Provider Details

I. General information

NPI: 1982756565
Provider Name (Legal Business Name): SHIYAMA MUDALI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

V. Phone/Fax

Practice location:
  • Phone: 302-320-2695
  • Fax: 302-320-4618
Mailing address:
  • Phone: 302-320-2695
  • Fax: 302-320-4618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number35.120826
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License NumberC1-0027278
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME108420
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC1-0027278
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: