Provider Demographics
NPI:1215978887
Name:PAUL, SIVANTA J (MD)
Entity type:Individual
Prefix:
First Name:SIVANTA
Middle Name:J
Last Name:PAUL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19949
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-0949
Mailing Address - Country:US
Mailing Address - Phone:904-279-1666
Mailing Address - Fax:904-279-1665
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 703
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6280
Practice Address - Country:US
Practice Address - Phone:904-279-1666
Practice Address - Fax:904-279-1665
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME564952084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
27201AMedicare ID - Type Unspecified
F03881Medicare UPIN