Provider Demographics
NPI:1083140081
Name:SMALLWOOD, SHAYNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAYNA
Middle Name:
Last Name:SMALLWOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14311 METROPOLIS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4442
Mailing Address - Country:US
Mailing Address - Phone:239-768-0127
Mailing Address - Fax:239-768-0671
Practice Address - Street 1:14311 METROPOLIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4442
Practice Address - Country:US
Practice Address - Phone:239-768-0127
Practice Address - Fax:239-768-0671
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME146132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107515000Medicaid
FLVR1ZKOtherBCBS