Provider Demographics
NPI:1760476766
Name:SHAH, ASHOK CHAMPAKLAL (MD)
Entity Type:Individual
Prefix:
First Name:ASHOK
Middle Name:CHAMPAKLAL
Last Name:SHAH
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:PO BOX 1980
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1980
Mailing Address - Country:US
Mailing Address - Phone:321-268-2005
Mailing Address - Fax:321-264-2235
Practice Address - Street 1:3808 S HOPKINS AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5753
Practice Address - Country:US
Practice Address - Phone:321-268-2005
Practice Address - Fax:321-264-2235
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26294OtherBCBS
FL26294YMedicare ID - Type Unspecified
F66492Medicare UPIN