Healthcare Provider Details

I. General information

NPI: 1629564786
Provider Name (Legal Business Name): SHIVA MUKUND ARJUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MUKUND SHIVARJUN SANKARAMOORTHY

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date: 02/13/2019
Reactivation Date: 02/18/2019

III. Provider practice location address

3480 POLYNESIAN ISLE BLVD
KISSIMMEE FL
34746-4654
US

IV. Provider business mailing address

2201 HEMPSTEAD TURNPIKE DEPARTMENT OF INTERNAL MEDICINE
EAST MEADOW NY
11554
US

V. Phone/Fax

Practice location:
  • Phone: 407-507-2615
  • Fax:
Mailing address:
  • Phone: 516-572-6501
  • Fax: 516-572-5609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number166809
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number323181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: