Healthcare Provider Details

I. General information

NPI: 1710304746
Provider Name (Legal Business Name): KUSH SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3657 MADACA LN STE 104
TAMPA FL
33618-2048
US

IV. Provider business mailing address

3820 NORTHDALE BLVD STE 201
TAMPA FL
33624-1893
US

V. Phone/Fax

Practice location:
  • Phone: 800-991-6117
  • Fax: 888-812-8191
Mailing address:
  • Phone: 800-991-6117
  • Fax: 888-812-8191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberME145681
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME145681
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number27275
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: