Provider Demographics
NPI:1972558617
Name:YAMAJALA, SIVARAM K (MD)
Entity type:Individual
Prefix:DR
First Name:SIVARAM
Middle Name:K
Last Name:YAMAJALA
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 1:871 VARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-459-4544
Mailing Address - Fax:978-970-1501
Practice Address - Street 1:871 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-459-4544
Practice Address - Fax:978-970-1501
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA072112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3083683Medicaid
MA072112OtherTUFTS
MAJ11633OtherBCBS
MA072112OtherTUFTS
MAJ11633OtherBCBS