Provider Demographics
NPI:1285691642
Name:SHIVERS, LEILANI GYENING (MD)
Entity type:Individual
Prefix:
First Name:LEILANI
Middle Name:GYENING
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1527
Mailing Address - Country:US
Mailing Address - Phone:706-571-1454
Mailing Address - Fax:706-660-2750
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1454
Practice Address - Fax:706-660-2750
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA399581263AMedicaid
GA399581263AMedicaid