Basic Information
| Provider Information | |||||||||
| NPI: | 1972559896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIVADAS | ||||||||
| FirstName: | ANITA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5213 S ALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204917 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Practice Location | |||||||||
| Address1: | 5832 FAYETTEVILLE RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277136290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446644 | ||||||||
| FaxNumber: | 9195440934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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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 | 35087481 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 201001362 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 2010-01362 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 166560 | 01 | NC | NC LICENSE | OTHER | 2654686 | 05 | OH | MEDICAID |