Provider Demographics
NPI:1134334790
Name:CITRUS PARK MEDICAL
Entity type:Organization
Organization Name:CITRUS PARK MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-343-5500
Mailing Address - Street 1:6328 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4122
Mailing Address - Country:US
Mailing Address - Phone:813-343-5500
Mailing Address - Fax:
Practice Address - Street 1:6328 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4122
Practice Address - Country:US
Practice Address - Phone:813-343-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50876207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03966OtherBCBS
FL206018OtherAVMED
FL00291OtherSTAYWELL
FL04953OtherUNIVERSAL MEDICAL
FL228737OtherAMERIGROUP
FL00291OtherSTAYWELL
FLD60999Medicare UPIN