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General NPI Number Information
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NPI Number | 1356311351
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Entity Type | Individual
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Provider Name | DODDACHALLOR MATT SHIVAKUMAR M.D.,
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Gender | Male
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Dates
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Enumeration Date | 01/24/2006
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Last Update Date | 09/08/2010
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Provider Practice Location Address
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Address Line | 908 S LINCOLN BLVD
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City | HODGENVILLE
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State | KY
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Zip | 42748-1702
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Country | US
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Telephone | 270-358-8650
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Fax | 270-358-0084
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Provider Business Mailing Address
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Address Line | 908 S LINCOLN BLVD
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City | HODGENVILLE
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State | KY
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Zip | 42748-1702
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Country | US
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Telephone | 270-358-8650
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Fax | 270-358-0084
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | KY20452
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License Number State | KY
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