1598718801 NPI number — SHIRINE MARIANNE GHARDA MD

Table of content: CHARLES SKLENER (NPI 1952914723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598718801 NPI number — SHIRINE MARIANNE GHARDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHARDA
Provider First Name:
SHIRINE
Provider Middle Name:
MARIANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GHARDA-WARD
Provider Other First Name:
SHIRINE
Provider Other Middle Name:
SAMYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598718801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7643 GATE PKWY STE 104
Provider Second Line Business Mailing Address:
PMB 125
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-2892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-472-8009
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 CRILL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32177-9230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-326-0575
Provider Business Practice Location Address Fax Number:
866-653-0629
Provider Enumeration Date:
05/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  ME58156 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0505X , with the licence number: ME58156 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 064646600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".