Provider Demographics
NPI:1033748298
Name:SATHIVADIVEL, NIROSHAN (MD)
Entity type:Individual
Prefix:
First Name:NIROSHAN
Middle Name:
Last Name:SATHIVADIVEL
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 1:1006 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4103
Mailing Address - Country:US
Mailing Address - Phone:877-678-7500
Mailing Address - Fax:
Practice Address - Street 1:1006 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4103
Practice Address - Country:US
Practice Address - Phone:877-678-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3406792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry