Healthcare Provider Details

I. General information

NPI: 1295007102
Provider Name (Legal Business Name): BLANE T SHATKIN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 TOWN CENTER CIR SUITE C
WESTON FL
33326-3640
US

IV. Provider business mailing address

1604 TOWN CENTER CIR SUITE C
WESTON FL
33326-3640
US

V. Phone/Fax

Practice location:
  • Phone: 954-384-9997
  • Fax: 954-384-6760
Mailing address:
  • Phone: 954-384-9997
  • Fax: 954-384-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME0059767
License Number StateFL

VIII. Authorized Official

Name: DR. BLANE T SHATKIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 954-384-9997