Healthcare Provider Details

I. General information

NPI: 1306337753
Provider Name (Legal Business Name): SHIVANAND VIJAY PERSAD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 W PALMETTO PARK RD STE 30
BOCA RATON FL
33433-3463
US

IV. Provider business mailing address

7050 W PALMETTO PARK RD STE 30
BOCA RATON FL
33433-3463
US

V. Phone/Fax

Practice location:
  • Phone: 954-425-9154
  • Fax: 866-981-1882
Mailing address:
  • Phone: 954-425-9154
  • Fax: 866-981-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME135224
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: