Healthcare Provider Details

I. General information

NPI: 1386780302
Provider Name (Legal Business Name): KIUMARS E. SHAMS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5389 COTTON ST
GRACEVILLE FL
32440-1739
US

IV. Provider business mailing address

PO BOX 186
GRACEVILLE FL
32440-0186
US

V. Phone/Fax

Practice location:
  • Phone: 850-360-4147
  • Fax: 850-360-4068
Mailing address:
  • Phone: 850-360-4147
  • Fax: 850-360-4068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME29949
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberME29949
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME29949
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: