Healthcare Provider Details

I. General information

NPI: 1013180553
Provider Name (Legal Business Name): SAMIR KAUSHIK SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 01/27/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 SW 16TH ST RM 3230
GAINESVILLE FL
32608-1128
US

IV. Provider business mailing address

1329 SW 16TH ST RM 3230
GAINESVILLE FL
32608-1128
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5484
  • Fax:
Mailing address:
  • Phone: 352-273-5484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number258805
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: