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 1:4343 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2437
Mailing Address - Country:US
Mailing Address - Phone:229-312-1000
Mailing Address - Fax:
Practice Address - Street 1:2336 DAWSON RD STE 1500
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2802
Practice Address - Country:US
Practice Address - Phone:229-312-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12648OtherLICENSE