Provider Demographics
NPI:1295703064
Name:SHAH, DIPAK (MD)
Entity type:Individual
Prefix:DR
First Name:DIPAK
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DIPAK
Other - Middle Name:
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDPA
Mailing Address - Street 1:10051 5TH ST N
Mailing Address - Street 2:STE 200
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2289
Mailing Address - Country:US
Mailing Address - Phone:813-265-2066
Mailing Address - Fax:813-960-4615
Practice Address - Street 1:14701 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1823
Practice Address - Country:US
Practice Address - Phone:813-265-2066
Practice Address - Fax:813-960-4615
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258794700Medicaid
FL258794700Medicaid
FL77640Medicare PIN