Provider Demographics
NPI:1356339519
Name:SHAHLA, AMER (MD)
Entity type:Individual
Prefix:
First Name:AMER
Middle Name:
Last Name:SHAHLA
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 1:1141 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3445
Mailing Address - Country:US
Mailing Address - Phone:904-249-3820
Mailing Address - Fax:904-249-3390
Practice Address - Street 1:1141 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3445
Practice Address - Country:US
Practice Address - Phone:904-249-3820
Practice Address - Fax:904-249-3390
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL70355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252413900Medicaid
FL252413900Medicaid
FL31259Medicare ID - Type Unspecified