Healthcare Provider Details

I. General information

NPI: 1972246023
Provider Name (Legal Business Name): SHANNON SARAH VARUGHESE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

V. Phone/Fax

Practice location:
  • Phone: 863-280-6080
  • Fax:
Mailing address:
  • Phone: 863-280-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS21178
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: