Provider Demographics
NPI:1902801921
Name:SIVASUBRAMANIAM, VISAHARAN (MD)
Entity Type:Individual
Prefix:
First Name:VISAHARAN
Middle Name:
Last Name:SIVASUBRAMANIAM
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 1:73 THOMPSON POYNTER ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-862-0605
Mailing Address - Fax:606-862-4899
Practice Address - Street 1:1380 HIGHWAY 192 E
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3123
Practice Address - Country:US
Practice Address - Phone:606-862-0605
Practice Address - Fax:606-862-4899
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38197207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64071939Medicaid
KY000000325000OtherBLUE CROSS BLUE SHEILD
KYP00107535OtherRAILROAD MEDICARE
KY000000325000OtherBLUE CROSS BLUE SHEILD
KY64071939Medicaid
KYH85514Medicare UPIN