Provider Demographics
NPI:1790940138
Name:CHANDRAKANT SHAH MD PA
Entity Type:Organization
Organization Name:CHANDRAKANT SHAH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDRAKANT
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-382-4901
Mailing Address - Street 1:13033 SW 112TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4601
Mailing Address - Country:US
Mailing Address - Phone:305-382-4901
Mailing Address - Fax:305-382-4502
Practice Address - Street 1:13033 SW 112TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4601
Practice Address - Country:US
Practice Address - Phone:305-382-4901
Practice Address - Fax:305-382-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0061676261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14792OtherMEDICARE ID
FL058773703Medicaid