Healthcare Provider Details

I. General information

NPI: 1275878787
Provider Name (Legal Business Name): SHAFFER RANDALL SHROPE MOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD452678
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME153258
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: