Healthcare Provider Details

I. General information

NPI: 1154326973
Provider Name (Legal Business Name): HEMANT N SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9421 WAYPOINT PL
JACKSONVILLE FL
32257-9229
US

IV. Provider business mailing address

PO BOX 600290
JACKSONVILLE FL
32260-0290
US

V. Phone/Fax

Practice location:
  • Phone: 904-268-8200
  • Fax: 904-268-8298
Mailing address:
  • Phone: 904-268-8200
  • Fax: 904-268-8298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME95262
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: