Provider Demographics
NPI:1902826035
Name:SHAH, MANISH N (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:N
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 1:2038 ASHLEY OAKS CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6413
Mailing Address - Country:US
Mailing Address - Phone:813-929-3622
Mailing Address - Fax:813-929-3620
Practice Address - Street 1:2038 ASHLEY OAKS DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-7013
Practice Address - Country:US
Practice Address - Phone:813-929-3622
Practice Address - Fax:813-929-3620
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81346207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264577700Medicaid
FL17002OtherBCBS
FL200897697OtherTIN
FL17002OtherBCBS
FL17002AMedicare PIN