Healthcare Provider Details

I. General information

NPI: 1790305308
Provider Name (Legal Business Name): SHAYAN FAIQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date: 01/10/2022
Reactivation Date: 10/19/2022

III. Provider practice location address

4200 SUN N LAKE BLVD
SEBRING FL
33872-1986
US

IV. Provider business mailing address

11511 SHADOW CREEK PKWY CREDENTIALING SERVICES
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 863-402-3402
  • Fax:
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME160337
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberW5787
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: