Provider Demographics
NPI:1093860199
Name:SAFWAN SHAMS,M.D.,P.A.
Entity Type:Organization
Organization Name:SAFWAN SHAMS,M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAFWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-586-1810
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-0883
Mailing Address - Country:US
Mailing Address - Phone:386-586-1810
Mailing Address - Fax:386-586-1811
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 1-800A
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-586-1810
Practice Address - Fax:386-586-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME036504174400000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18020Medicare ID - Type Unspecified