Healthcare Provider Details

I. General information

NPI: 1407379688
Provider Name (Legal Business Name): SHUBHAM SURESH JAISWAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16400 S HIGHWAY 25
WEIRSDALE FL
32195-2442
US

IV. Provider business mailing address

16400 S HIGHWAY 25
WEIRSDALE FL
32195-2442
US

V. Phone/Fax

Practice location:
  • Phone: 352-821-9797
  • Fax: 352-821-0553
Mailing address:
  • Phone: 352-821-9797
  • Fax: 352-821-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME150813
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: