Provider Demographics
NPI:1750125209
Name:PATEL, SHIVAM PINAKIN
Entity type:Individual
Prefix:
First Name:SHIVAM
Middle Name:PINAKIN
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4335 EMERALD PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3504
Mailing Address - Country:US
Mailing Address - Phone:863-624-4096
Mailing Address - Fax:
Practice Address - Street 1:1459 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0002
Practice Address - Country:US
Practice Address - Phone:706-721-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA16728207R00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine