=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922458611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BHAVAN UPENDRAKUMAR SHAH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2016
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11215 METRO PKWY STE 1
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33966-1206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-208-2212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8321 LAFAYETTE LN
-----------------------------------------------------
City | FOGELSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18051-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-452-3918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | MD474975
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 57.027713
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD214692
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 50138
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD474975
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME159372
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------