Healthcare Provider Details

I. General information

NPI: 1568091197
Provider Name (Legal Business Name): SHANE THOMAS GEFFE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE
FORT MYERS FL
33901-5858
US

IV. Provider business mailing address

5862 MUSKET LN
STONE MOUNTAIN GA
30087-1707
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-2551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME152216
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number96067
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: