Provider Demographics
NPI:1407379688
Name:JAISWAL, SHUBHAM SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUBHAM
Middle Name:SURESH
Last Name:JAISWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16400 S HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:WEIRSDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32195-2442
Mailing Address - Country:US
Mailing Address - Phone:352-821-9797
Mailing Address - Fax:352-821-0553
Practice Address - Street 1:16400 S HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:WEIRSDALE
Practice Address - State:FL
Practice Address - Zip Code:32195-2442
Practice Address - Country:US
Practice Address - Phone:352-821-9797
Practice Address - Fax:352-821-0553
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME150813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program