Healthcare Provider Details

I. General information

NPI: 1356082044
Provider Name (Legal Business Name): SHIVAM KHOSLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 PROFESSIONAL CENTER DR STE 101
ORANGE PARK FL
32073-4461
US

IV. Provider business mailing address

2021 PROFESSIONAL CENTER DR STE 101
ORANGE PARK FL
32073-4461
US

V. Phone/Fax

Practice location:
  • Phone: 904-213-9210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS24072
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: