Provider Demographics
NPI:1124384789
Name:SHANKER-PATEL, KAVITA (MD)
Entity Type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:SHANKER-PATEL
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3614 PROVIDENCE RD S STE 200
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6310
Practice Address - Country:US
Practice Address - Phone:704-384-8640
Practice Address - Fax:704-384-8650
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138106207Q00000X
IL125061830207Q00000X
NC2022-01815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920540OtherMEDICARE PTAN (GROUP)
ILF400250954OtherMEDICARE PTAN (INDIVIDUAL)
IL036138106OtherMEDICAID