Healthcare Provider Details

I. General information

NPI: 1558517680
Provider Name (Legal Business Name): GIRIDHAR MYSORE SHIVARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GIRI SHIVARAM MD

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 07/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE M/S MA.7.220, PO BOX 5371
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2166
  • Fax:
Mailing address:
  • Phone: 206-987-2166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD60180267
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60180267
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD60180267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: