MEDICARE: SEAN SHAHLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME0071346	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801884119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN SHAHLA MD

Provider Business Mailing Address
First Line	:	1141 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32250-3445
Country	:	US
Telephone Number	:	904-249-3820
Fax Number	:	904-249-3390

Provider Business Practice Location Address
First Line	:	1141 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3445
Country	:	US
Telephone Number	:	904-249-3820
Fax Number	:	904-249-3390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	06/22/2010

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Directions to “ SEAN SHAHLA MD” Practice Location

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