Healthcare Provider Details

I. General information

NPI: 1992490684
Provider Name (Legal Business Name): SHIVANI JAGDISH PATEL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 PEACHTREE PKWY STE 100
NORCROSS GA
30092-2823
US

IV. Provider business mailing address

1975 HIGHWAY 54 W STE 205
PEACHTREE CITY GA
30269-4794
US

V. Phone/Fax

Practice location:
  • Phone: 770-368-6215
  • Fax: 770-368-6261
Mailing address:
  • Phone: 770-716-8732
  • Fax: 770-487-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD305030
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: