Basic Information
| Provider Information | |||||||||
| NPI: | 1932328747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIVAGNANAM | ||||||||
| FirstName: | MAMATA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ENGINEER | ||||||||
| OtherFirstName: | MAMATA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3860 CALLE FORTUNADA | ||||||||
| Address2: | STE #210 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096303 | ||||||||
| FaxNumber: | 8583096301 | ||||||||
| Practice Location | |||||||||
| Address1: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | BLDG 28 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589664003 | ||||||||
| FaxNumber: | 8585606798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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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 | 2080P0206X | A86863 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.