Healthcare Provider Details

I. General information

NPI: 1154958163
Provider Name (Legal Business Name): SUNNY SHAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 METRO PKWY
FORT MYERS FL
33966-1206
US

IV. Provider business mailing address

1147 NW 64TH TER
GAINESVILLE FL
32605-4218
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-2212
  • Fax: 239-208-3994
Mailing address:
  • Phone: 352-333-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberUO7234
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDR.0073131
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025031712
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: