Provider Demographics
NPI:1679701262
Name:ANITA SIVASUBRAMANIAN M.D., INC
Entity type:Organization
Organization Name:ANITA SIVASUBRAMANIAN M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVASUBRAMANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-360-9589
Mailing Address - Street 1:7035 N CHESTNUT AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-0352
Mailing Address - Country:US
Mailing Address - Phone:559-353-2300
Mailing Address - Fax:559-353-2323
Practice Address - Street 1:7035 N CHESTNUT AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0352
Practice Address - Country:US
Practice Address - Phone:559-353-2300
Practice Address - Fax:559-353-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A743870Medicaid
CACB885AOtherMEDICARE PTAN
CACB885AOtherMEDICARE PTAN
CA00A743870Medicaid