Provider Demographics
NPI:1407879752
Name:STALLER, SHELDON (MD)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:STALLER
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 1:8750 NW 36TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2499
Mailing Address - Country:US
Mailing Address - Phone:305-262-1610
Mailing Address - Fax:305-907-6099
Practice Address - Street 1:150 NW 168TH ST STE 301
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-6051
Practice Address - Country:US
Practice Address - Phone:305-654-5440
Practice Address - Fax:305-654-5445
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME16525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10752OtherHUMANA
005880OtherNEIGHBORHOOD
1196818OtherCIGNA
0470110OtherUNITED
216805OtherAVMED
228OtherVISTA
91717OtherHEALTHOPTIONS
5090400OtherAETNA
207375OtherMARIGROUP
FL91717MMedicare PIN
10752OtherHUMANA
91717OtherHEALTHOPTIONS
FL97500AMedicare PIN