Provider Demographics
NPI:1578536793
Name:SHAH, SITA (MD)
Entity Type:Individual
Prefix:DR
First Name:SITA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 OAKLANDING LN
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-9015
Mailing Address - Country:US
Mailing Address - Phone:904-728-8533
Mailing Address - Fax:
Practice Address - Street 1:1332 OAKLANDING LN
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-9015
Practice Address - Country:US
Practice Address - Phone:904-728-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME764752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300089806OtherRR CARE
FL2546531-00Medicaid
GA000801996AMedicaid
FLG75480Medicare UPIN
FL2546531-00Medicaid