Provider Demographics
NPI:1528591716
Name:DESAI, SHIVAM (MD)
Entity Type:Individual
Prefix:
First Name:SHIVAM
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 SMOKESTONE DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4989
Mailing Address - Country:US
Mailing Address - Phone:678-521-0935
Mailing Address - Fax:
Practice Address - Street 1:4904 TIMBER RIDGE DR STE 102
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1831
Practice Address - Country:US
Practice Address - Phone:678-401-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine