Healthcare Provider Details

I. General information

NPI: 1710525662
Provider Name (Legal Business Name): SIVAM DIABETES & PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 09/01/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120-1122 SOUTH ORANGE AVENUE
NEWARK NJ
07106
US

IV. Provider business mailing address

78 KENMORE AVE
NEWARK NJ
07106-1026
US

V. Phone/Fax

Practice location:
  • Phone: 201-618-1472
  • Fax:
Mailing address:
  • Phone: 201-618-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MAVIS CAMALITA ERMAKOV
Title or Position: DIRECTOR/CEO
Credential: DNP, APN, FHNP-BC, R
Phone: 201-618-1472