Provider Demographics
NPI:1003010349
Name:SHAYA, WISSAM M (MD)
Entity Type:Individual
Prefix:DR
First Name:WISSAM
Middle Name:M
Last Name:SHAYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:4235 SUNBEAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6013
Practice Address - Country:US
Practice Address - Phone:904-322-8555
Practice Address - Fax:904-322-8578
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123703207Q00000X
MI4301082473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015772000Medicaid
FLNY876OtherMEDICARE