Healthcare Provider Details

I. General information

NPI: 1346446911
Provider Name (Legal Business Name): CHETAN CHANDULAL SHAH M.B.B.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-8426
US

IV. Provider business mailing address

PO BOX 100374
GAINESVILLE FL
32610-0374
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0291
  • Fax: 352-265-0279
Mailing address:
  • Phone: 352-265-0291
  • Fax: 352-265-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberE-5677
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberC10010212
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberE-5677
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberME113302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: