Provider Demographics
NPI:1598718801
Name:GHARDA, SHIRINE MARIANNE (MD)
Entity Type:Individual
Prefix:
First Name:SHIRINE
Middle Name:MARIANNE
Last Name:GHARDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHIRINE
Other - Middle Name:SAMYN
Other - Last Name:GHARDA-WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7643 GATE PKWY STE 104
Mailing Address - Street 2:PMB 125
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2892
Mailing Address - Country:US
Mailing Address - Phone:904-472-8009
Mailing Address - Fax:
Practice Address - Street 1:6500 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9230
Practice Address - Country:US
Practice Address - Phone:386-326-0575
Practice Address - Fax:866-653-0629
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58156207P00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064646600Medicaid
FL11463DMedicare ID - Type Unspecified
FL064646600Medicaid