Healthcare Provider Details

I. General information

NPI: 1083148589
Provider Name (Legal Business Name): SHALINI THAREJA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date: 10/27/2020
Reactivation Date: 12/03/2020

III. Provider practice location address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

IV. Provider business mailing address

675 S BABCOCK ST
MELBOURNE FL
32901-1459
US

V. Phone/Fax

Practice location:
  • Phone: 321-951-1010
  • Fax: 321-952-4038
Mailing address:
  • Phone: 321-951-1010
  • Fax: 321-952-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME145980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: