Healthcare Provider Details

I. General information

NPI: 1720433451
Provider Name (Legal Business Name): SAMIR SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 US HIGHWAY 19
PORT RICHEY FL
34668-2885
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 352-691-5050
  • Fax: 352-691-5052
Mailing address:
  • Phone: 352-277-5305
  • Fax: 352-616-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number29216
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME146526
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: