Healthcare Provider Details

I. General information

NPI: 1205357688
Provider Name (Legal Business Name): SYED RAZA SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 NW 64TH TER
GAINESVILLE FL
32605-4218
US

IV. Provider business mailing address

1147 NW 64TH TER
GAINESVILLE FL
32605-4218
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-5159
  • Fax:
Mailing address:
  • Phone: 352-333-5159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN25632
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number53520
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD478957
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: