Healthcare Provider Details

I. General information

NPI: 1073662789
Provider Name (Legal Business Name): SHAYAN VYAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE STE 100 NEMOURS CHILDRENS CLINIC
ORLANDO FL
32806-2946
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-650-7715
  • Fax: 407-650-7124
Mailing address:
  • Phone: 302-651-6718
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME105218
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME105218
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: