Healthcare Provider Details

I. General information

NPI: 1659329308
Provider Name (Legal Business Name): MONA JAY SHAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE UNIT 604
JACKSONVILLE FL
32256-9686
US

IV. Provider business mailing address

11512 LAKE MEAD AVE UNIT 604
JACKSONVILLE FL
32256-9686
US

V. Phone/Fax

Practice location:
  • Phone: 904-717-3510
  • Fax: 904-667-0101
Mailing address:
  • Phone: 904-717-3510
  • Fax: 904-667-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberME94951
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME94951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: