Provider Demographics
NPI:1922529767
Name:SHAH, PRERNA (DO)
Entity Type:Individual
Prefix:
First Name:PRERNA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 BROOKER CREEK BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2937
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-436-5378
Practice Address - Street 1:1001 LAUREL OAK RD STE B
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3512
Practice Address - Country:US
Practice Address - Phone:856-782-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-02
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NJ25MB10829100208000000X
FLOS20801208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program