Provider Demographics
NPI:1255403663
Name:SHAH, BHAVESH A (MD)
Entity type:Individual
Prefix:DR
First Name:BHAVESH
Middle Name:A
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 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST STE 405
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2941
Practice Address - Country:US
Practice Address - Phone:941-917-3500
Practice Address - Fax:941-917-3501
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101053207Q00000X
FLME145449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400268164OtherMEDICARE PTAN INDIVIDUAL
IL920540OtherMEDICARE PTAN GROUP
IL920540OtherMEDICARE PTAN GROUP
IL203958Medicare ID - Type Unspecified