Provider Demographics
NPI:1174510358
Name:SHAH, SIDDHARTH H (MD)
Entity Type:Individual
Prefix:
First Name:SIDDHARTH
Middle Name:H
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:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:ELFERS
Mailing Address - State:FL
Mailing Address - Zip Code:34680-0768
Mailing Address - Country:US
Mailing Address - Phone:727-848-0800
Mailing Address - Fax:727-843-8157
Practice Address - Street 1:4762 ROWAN RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-5601
Practice Address - Country:US
Practice Address - Phone:727-848-0800
Practice Address - Fax:727-843-8157
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00681652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377497000Medicaid
FLG04117Medicare UPIN
FL377497000Medicaid