Healthcare Provider Details

I. General information

NPI: 1932399045
Provider Name (Legal Business Name): SHALAKA GHATE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 A1A N STE 1
PONTE VEDRA BEACH FL
32082-5212
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-273-6900
  • Fax: 904-390-7479
Mailing address:
  • Phone: 903-290-2103
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME99114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: