Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 073655 | GA |
NPI | 1023226081 |
---|---|
Provider Name | Praveen Sivakumaran |
First Address | Snellville, GA 30078-6756 |
Second Address | Lawrenceville, GA 30046-3370 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2007 |
Last Update Date | 10/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003159182B | (05) | GA |
2021831397 | PTAN (01) | GA |