Provider Demographics
NPI:1730388067
Name:THEIVANAYAGAM, SHOBA (MD)
Entity type:Individual
Prefix:DR
First Name:SHOBA
Middle Name:
Last Name:THEIVANAYAGAM
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:PO BOX 782009
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32878-2009
Mailing Address - Country:US
Mailing Address - Phone:407-201-3686
Mailing Address - Fax:407-201-3739
Practice Address - Street 1:812 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-6625
Practice Address - Country:US
Practice Address - Phone:407-201-3686
Practice Address - Fax:407-201-3739
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148442207RG0100X
MO2011001511207RG0100X
IL036.125213207RG0100X
IAMD-44502207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology