Healthcare Provider Details

I. General information

NPI: 1942122197
Provider Name (Legal Business Name): SHIVA VISWANATH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 N NOTRE DAME AVE
SOUTH BEND IN
46617-1404
US

IV. Provider business mailing address

10501 TREBAH CIR
CARMEL IN
46032-9709
US

V. Phone/Fax

Practice location:
  • Phone: 574-631-5574
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: