Provider Demographics
NPI:1083148589
Name:THAREJA, SHALINI (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHALINI
Middle Name:
Last Name:THAREJA
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 1:675 S BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1459
Mailing Address - Country:US
Mailing Address - Phone:321-951-1010
Mailing Address - Fax:321-952-4038
Practice Address - Street 1:675 S BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1459
Practice Address - Country:US
Practice Address - Phone:321-951-1010
Practice Address - Fax:321-952-4038
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2020-12-03
Deactivation Date:2020-10-27
Deactivation Code:
Reactivation Date:2020-12-03
Provider Licenses
StateLicense IDTaxonomies
FLME145980207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology