Healthcare Provider Details

I. General information

NPI: 1467640151
Provider Name (Legal Business Name): MUBARIK AHMAD SHAH MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 VIA POINCIANA SUITE 10
LAKE WORTH FL
33467-2991
US

IV. Provider business mailing address

3918 VIA POINCIANA SUITE 10
LAKE WORTH FL
33467-2991
US

V. Phone/Fax

Practice location:
  • Phone: 561-721-3939
  • Fax: 561-439-6851
Mailing address:
  • Phone: 561-721-3939
  • Fax: 561-439-6851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME89362
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME89362
License Number StateFL

VIII. Authorized Official

Name: MUBARIK A SHAH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-721-3939