Healthcare Provider Details

I. General information

NPI: 1568853844
Provider Name (Legal Business Name): IFFAT SHAHEEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TECHNOLOGY PARK STE 109
LAKE MARY FL
32746-7107
US

IV. Provider business mailing address

148 PRESTWICK GRANDE DR
DAYTONA BEACH FL
32124-3032
US

V. Phone/Fax

Practice location:
  • Phone: 407-647-2346
  • Fax: 407-647-5431
Mailing address:
  • Phone: 601-883-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31779
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.139188
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME153944
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME153944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: