Provider Demographics
NPI:1376599746
Name:SHIVDAT, JOHN A (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:SHIVDAT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 GRAND OAKS GLN NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5423
Mailing Address - Country:US
Mailing Address - Phone:770-424-0901
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:1120 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2906
Practice Address - Country:US
Practice Address - Phone:478-988-1706
Practice Address - Fax:478-988-1794
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47527207P00000X
NJ25MB06152500207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6848109Medicaid
NJP00630321OtherMEDICARE RAILROAD
NJP00630321OtherMEDICARE RAILROAD
NJ831163SN3Medicare PIN
NJ831163CLDMedicare PIN
G21215Medicare UPIN
NJ831163MK3Medicare PIN
NJ831163DPHMedicare PIN