MEDICARE: MR. SHIVASHANKARA SWAMY MATHIGHATTA SHIVARUDRAIAH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1154268449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHIVASHANKARA SWAMY MATHIGHATTA SHIVARUDRAIAH

Provider Business Mailing Address
First Line	:	1054 41 STREET APT 2G
Second Line	:	APT 2G
City	:	BROOKLYN
State	:	NY
Zip	:	11219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4802 10TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219
Country	:	US
Telephone Number	:	718-283-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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