Provider Demographics
NPI:1801845607
Name:SHIVASHANKAR, LATHA (MD)
Entity Type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:SHIVASHANKAR
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 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-998-1448
Mailing Address - Fax:904-998-1450
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-998-1448
Practice Address - Fax:904-998-1450
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53102208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058765600Medicaid