Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | 201029319 | MO |
N | 208000000X | Pediatrician | P23802 | MD |
NPI | 1700021706 |
---|---|
Provider Name | Dr. Shivarajan Manickavasagam Amudhavalli |
First Address | Kansas City, MO 64108-4619 |
Second Address | Kansas City, MO 64108-4619 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2008 |
Last Update Date | 26/10/2012 |