Provider Demographics
NPI:1639128416
Name:SHEA, ROGER MARKS (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MARKS
Last Name:SHEA
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 1:5432 BEE RIDGE RD
Mailing Address - Street 2:STE # 140
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233
Mailing Address - Country:US
Mailing Address - Phone:941-371-2244
Mailing Address - Fax:941-371-1144
Practice Address - Street 1:5432 BEE RIDGE RD
Practice Address - Street 2:STE # 140
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233
Practice Address - Country:US
Practice Address - Phone:941-371-2244
Practice Address - Fax:941-371-1144
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065243207YP0228X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379122000Medicaid
FL27118Medicare ID - Type Unspecified