Healthcare Provider Details

I. General information

NPI: 1811181076
Provider Name (Legal Business Name): SHAISTA SYEDA SAFDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W GORE ST
ORLANDO FL
32806-1141
US

IV. Provider business mailing address

60 W GORE ST
ORLANDO FL
32806-1141
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-3338
  • Fax: 321-841-2170
Mailing address:
  • Phone: 321-841-3338
  • Fax: 321-841-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberME104910
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberAU2866626-U156
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: