Healthcare Provider Details

I. General information

NPI: 1235283292
Provider Name (Legal Business Name): SIVA SURYADEVARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST ACC, 5TH FLOOR
JACKSONVILLE FL
32209
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-2655
  • Fax: 904-244-5913
Mailing address:
  • Phone: 904-244-3065
  • Fax: 904-244-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME116319
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME 116319
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13556
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: