Provider Demographics
NPI:1932399045
Name:GHATE, SHALAKA (MD)
Entity Type:Individual
Prefix:
First Name:SHALAKA
Middle Name:
Last Name:GHATE
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:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:903-290-2103
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:520 A1A N STE 1
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5212
Practice Address - Country:US
Practice Address - Phone:904-273-6900
Practice Address - Fax:904-390-7479
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00984000Medicaid
FLAQ153ZMedicare PIN
FL00984000Medicaid