Healthcare Provider Details

I. General information

NPI: 1922458611
Provider Name (Legal Business Name): BHAVAN UPENDRAKUMAR SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

IV. Provider business mailing address

8321 LAFAYETTE LN
FOGELSVILLE PA
18051-7733
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax:
Mailing address:
  • Phone: 440-452-3918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMD474975
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57.027713
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD214692
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number50138
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD474975
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME159372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: