Provider Demographics
NPI:1902936578
Name:DIVAKARUNI, SHASHIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:SHASHIDHAR
Middle Name:
Last Name:DIVAKARUNI
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 1:1730 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3915
Mailing Address - Country:US
Mailing Address - Phone:219-836-9677
Mailing Address - Fax:219-836-0688
Practice Address - Street 1:1730 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3915
Practice Address - Country:US
Practice Address - Phone:219-836-9677
Practice Address - Fax:219-836-0688
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040667207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100200170BMedicaid
IL90000999OtherBCBSIL
IN000000173830OtherANTHEM
IN000000173830OtherANTHEM
IN215800AMedicare PIN