Provider Demographics
NPI:1023226081
Name:SIVAKUMARAN, PRAVEEN (MD)
Entity type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:
Last Name:SIVAKUMARAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TREE LN STE 490
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6756
Mailing Address - Country:US
Mailing Address - Phone:770-979-2828
Mailing Address - Fax:770-979-3139
Practice Address - Street 1:631 PROFESSIONAL DR STE 450
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3370
Practice Address - Country:US
Practice Address - Phone:770-963-8030
Practice Address - Fax:770-339-9577
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073655207RH0003X
CAA103104207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159182BMedicaid
GA2021831397OtherPTAN