Provider Demographics
NPI:1083280523
Name:PATEL, SHIVAN NARENDRA
Entity type:Individual
Prefix:
First Name:SHIVAN
Middle Name:NARENDRA
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-1978
Mailing Address - Country:US
Mailing Address - Phone:229-776-2965
Mailing Address - Fax:
Practice Address - Street 1:1014 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-1978
Practice Address - Country:US
Practice Address - Phone:229-776-2965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA99755OtherLICENSE