Provider Demographics
NPI:1952784274
Name:JERATH, SHIVANI
Entity Type:Individual
Prefix:DR
First Name:SHIVANI
Middle Name:
Last Name:JERATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-4588
Mailing Address - Fax:
Practice Address - Street 1:4143 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3805
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79638207Q00000X
NY296959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine