Provider Demographics
NPI:1477515302
Name:SHAH, MOHAN M (MD)
Entity Type:Individual
Prefix:
First Name:MOHAN
Middle Name:M
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S MISSOURI AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-4600
Mailing Address - Country:US
Mailing Address - Phone:863-682-0027
Mailing Address - Fax:863-682-3006
Practice Address - Street 1:115 S MISSOURI AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-4600
Practice Address - Country:US
Practice Address - Phone:863-682-0027
Practice Address - Fax:863-682-3006
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53099207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE22432Medicare UPIN