Healthcare Provider Details

I. General information

NPI: 1386271336
Provider Name (Legal Business Name): SHIVANI PATEL THACKAR DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10213 WATERSIDE OAKS DR
TAMPA FL
33647-3194
US

IV. Provider business mailing address

10213 WATERSIDE OAKS DR
TAMPA FL
33647-3194
US

V. Phone/Fax

Practice location:
  • Phone: 813-482-1508
  • Fax:
Mailing address:
  • Phone: 813-482-1508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberOS22612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: