Basic Information
| Provider Information | |||||||||
| NPI: | 1235234212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVANANDY | ||||||||
| FirstName: | MALA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 BROOKLINE AVENUE | ||||||||
| Address2: | GRYZMISH 6 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176671769 | ||||||||
| FaxNumber: | 6176677060 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVENUE | ||||||||
| Address2: | GRYZMISH 6 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176671769 | ||||||||
| FaxNumber: | 6176677060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 04/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35088569 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 239636 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 2686937 | 05 | OH | MEDICAID |