Provider Demographics
NPI:1205423373
Name:SHAH, KHUSSBU (OD)
Entity type:Individual
Prefix:
First Name:KHUSSBU
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7539
Mailing Address - Country:US
Mailing Address - Phone:813-284-2323
Mailing Address - Fax:813-377-1715
Practice Address - Street 1:14014 N 46TH ST STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4018
Practice Address - Country:US
Practice Address - Phone:813-284-2323
Practice Address - Fax:813-377-1715
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3644152W00000X
FLOPC6054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist