Provider Demographics
NPI:1235317397
Name:SHAHLA MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:SHAHLA MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-249-3820
Mailing Address - Street 1:1141 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3445
Mailing Address - Country:US
Mailing Address - Phone:904-249-3820
Mailing Address - Fax:904-249-3390
Practice Address - Street 1:1141 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3445
Practice Address - Country:US
Practice Address - Phone:904-249-3820
Practice Address - Fax:904-249-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN
FL=========OtherTIN