Provider Demographics
NPI:1710932405
Name:ATLANTIC EAR NOSE & THROAT PA
Entity Type:Organization
Organization Name:ATLANTIC EAR NOSE & THROAT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVANG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-774-9880
Mailing Address - Street 1:PO BOX 953577
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-3577
Mailing Address - Country:US
Mailing Address - Phone:386-774-9880
Mailing Address - Fax:
Practice Address - Street 1:963 TOWN CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8254
Practice Address - Country:US
Practice Address - Phone:386-774-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1273Medicare ID - Type Unspecified