Provider Demographics
NPI:1447260328
Name:SIVASUBRAMANIAN, ANITA (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:SIVASUBRAMANIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7489 N 1ST ST
Mailing Address - Street 2:STE 103
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2848
Mailing Address - Country:US
Mailing Address - Phone:559-446-0409
Mailing Address - Fax:559-446-0903
Practice Address - Street 1:7215 N FRESNO ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2969
Practice Address - Country:US
Practice Address - Phone:559-446-0409
Practice Address - Fax:559-446-0903
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA74387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A743870Medicaid
CA00A743870Medicare PIN
CA00A743870Medicaid