Healthcare Provider Details

I. General information

NPI: 1902839913
Provider Name (Legal Business Name): VRAJESH SHAH M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15953 N FLORIDA AVE
LUTZ FL
33549-8102
US

IV. Provider business mailing address

PO BOX 271447
TAMPA FL
33688-1447
US

V. Phone/Fax

Practice location:
  • Phone: 813-960-4894
  • Fax: 813-968-4997
Mailing address:
  • Phone: 813-960-4894
  • Fax: 813-968-4997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0061405
License Number StateFL

VIII. Authorized Official

Name: MARIE VANESSA MATOS
Title or Position: OFFICE MANAGER
Credential:
Phone: 813-960-4894