Healthcare Provider Details

I. General information

NPI: 1669671806
Provider Name (Legal Business Name): ROBERT SHANE WEATHERWAX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 ZEMKE AVE BLDG 1078
TAMPA FL
33621-5023
US

IV. Provider business mailing address

3250 ZEMKE AVE BLDG 1078
TAMPA FL
33621-5023
US

V. Phone/Fax

Practice location:
  • Phone: 813-827-9560
  • Fax:
Mailing address:
  • Phone: 813-827-9560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25743
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: