Provider Demographics
NPI:1013029289
Name:SHAH, GAURAV R (MD)
Entity Type:Individual
Prefix:
First Name:GAURAV
Middle Name:R
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 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:500 SE OSCEOLA ST
Practice Address - Street 2:STE 200
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2364
Practice Address - Country:US
Practice Address - Phone:772-286-1550
Practice Address - Fax:772-221-0569
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115947207RN0300X
WI48747207R00000X
IL036-113972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009080500Medicaid
FLHK209Medicare PIN
G57603Medicare UPIN
WI34831800Medicaid
FLHK209Medicare PIN