Provider Demographics
NPI:1669818845
Name:SHAH DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SHAH DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AYYAZ
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-629-8865
Mailing Address - Street 1:201 HILDA ST
Mailing Address - Street 2:SUITE 38
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2320
Mailing Address - Country:US
Mailing Address - Phone:407-629-8865
Mailing Address - Fax:407-629-8932
Practice Address - Street 1:201 HILDA ST
Practice Address - Street 2:SUITE 38
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2320
Practice Address - Country:US
Practice Address - Phone:407-629-8865
Practice Address - Fax:407-629-8932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10163207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty