Provider Demographics
NPI: | 1356306419 |
---|---|
Name: | SHUSTER, PAUL EMANUEL (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | PAUL |
Middle Name: | EMANUEL |
Last Name: | SHUSTER |
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: | 1845 VETERANS PARK DR STE 260 |
Mailing Address - Street 2: | |
Mailing Address - City: | NAPLES |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 34109-0494 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 239-624-0570 |
Mailing Address - Fax: | 239-254-7959 |
Practice Address - Street 1: | 1845 VETERANS PARK DR STE 260 |
Practice Address - Street 2: | |
Practice Address - City: | NAPLES |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34109-0494 |
Practice Address - Country: | US |
Practice Address - Phone: | 239-624-0570 |
Practice Address - Fax: | 239-254-7959 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-04-19 |
Last Update Date: | 2019-04-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | D0044819 | 2080A0000X |
FL | ME138747 | 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | |
No | 2080A0000X | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 447891600 | Medicaid | |
FL | 101706900 | Medicaid | |
FL | 7NE26 | Other | BCBS |