Basic Information
Provider Information | |||||||||
NPI: | 1700379187 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSTON | ||||||||
FirstName: | SHIVALI | ||||||||
MiddleName: | DIPAM PATEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1550 RODNEY RD | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 174089715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178468791 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1550 RODNEY RD | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 174089715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178468791 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2018 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OT018524 | PA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | OS020918 | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.