Provider Demographics
NPI:1902806193
Name:VADIVELU, SHANMUGHAM (MD)
Entity Type:Individual
Prefix:
First Name:SHANMUGHAM
Middle Name:
Last Name:VADIVELU
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 1:1507 WABASH ST
Mailing Address - Street 2:SUITE 400C
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4300
Mailing Address - Country:US
Mailing Address - Phone:219-871-0833
Mailing Address - Fax:219-871-0836
Practice Address - Street 1:1507 WABASH ST
Practice Address - Street 2:SUITE 400C
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4300
Practice Address - Country:US
Practice Address - Phone:219-871-0833
Practice Address - Fax:219-871-0836
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060743A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000366517OtherANTHEM BLUE SHIELD
IN000000366517OtherANTHEM BLUE SHIELD