Healthcare Provider Details

I. General information

NPI: 1033679493
Provider Name (Legal Business Name): SHIVAM VIPUL AMIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 NORMANDIE DR STE 314
MONTGOMERY AL
36111-2732
US

IV. Provider business mailing address

2101 HIGHLAND AVE S STE 350
BIRMINGHAM AL
35205-4009
US

V. Phone/Fax

Practice location:
  • Phone: 334-263-0105
  • Fax: 334-264-4386
Mailing address:
  • Phone: 334-263-0105
  • Fax: 334-264-4386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number125073564
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number81518
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD.50972
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: