Provider Demographics
NPI:1285713867
Name:SIVAKUMARAN, MUTHUMANIMOLI (MD)
Entity type:Individual
Prefix:
First Name:MUTHUMANIMOLI
Middle Name:
Last Name:SIVAKUMARAN
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 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:916-550-5003
Practice Address - Street 1:1276 HALYARD DR
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691
Practice Address - Country:US
Practice Address - Phone:855-354-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53008208000000X
WV18760B208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001722754OtherBCBS
WV0110583000Medicaid
WV550782614OtherTAX ID