Healthcare Provider Details

I. General information

NPI: 1639117997
Provider Name (Legal Business Name): YOGESH H SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 LIVE OAK ST SUITE A
NEW SMYRNA BEACH FL
32168-7312
US

IV. Provider business mailing address

501 LIVE OAK ST SUITE A
NEW SMYRNA BEACH FL
32168-7312
US

V. Phone/Fax

Practice location:
  • Phone: 386-426-2060
  • Fax: 386-426-6533
Mailing address:
  • Phone: 386-426-2060
  • Fax: 386-426-6533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME61678
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA04049300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101042153
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: