Provider Demographics
NPI:1154508083
Name:SHAH, VAIBHAV (MD)
Entity Type:Individual
Prefix:
First Name:VAIBHAV
Middle Name:
Last Name:SHAH
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 1:1978 US HIGHWAY 1 STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3722
Mailing Address - Country:US
Mailing Address - Phone:321-345-6331
Mailing Address - Fax:321-345-3295
Practice Address - Street 1:1978 US HIGHWAY 1 STE 103
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3722
Practice Address - Country:US
Practice Address - Phone:321-345-6331
Practice Address - Fax:321-345-3295
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1077072084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107707OtherFL MEDICAL LICENSE