Healthcare Provider Details

I. General information

NPI: 1760476766
Provider Name (Legal Business Name): ASHOK CHAMPAKLAL SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 S HOPKINS AVE
TITUSVILLE FL
32780-5753
US

IV. Provider business mailing address

PO BOX 1980
MELBOURNE FL
32902-1980
US

V. Phone/Fax

Practice location:
  • Phone: 321-268-2005
  • Fax: 321-264-2235
Mailing address:
  • Phone: 321-268-2005
  • Fax: 321-264-2235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME67131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: