Provider Demographics
NPI:1972559896
Name:SHIVADAS, ANITA (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:SHIVADAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4917
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:5832 FAYETTEVILLE RD
Practice Address - Street 2:SUITE 113
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6290
Practice Address - Country:US
Practice Address - Phone:919-544-6644
Practice Address - Fax:919-544-0934
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087481207R00000X
NC201001362207Q00000X
NC2010-01362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC166560OtherNC LICENSE
OH2654686Medicaid
OHSH7361491Medicare PIN
NC166560OtherNC LICENSE