Provider Demographics
NPI:1114639440
Name:PATEL, SHIV (DPT)
Entity Type:Individual
Prefix:
First Name:SHIV
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 PARK AVE N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2863
Mailing Address - Country:US
Mailing Address - Phone:229-326-9881
Mailing Address - Fax:
Practice Address - Street 1:360 MCDONOUGH PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8985
Practice Address - Country:US
Practice Address - Phone:229-326-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist