Provider Demographics
NPI:1356571525
Name:SHAH, MRUNAL VINODCHANDRA (MD)
Entity type:Individual
Prefix:
First Name:MRUNAL
Middle Name:VINODCHANDRA
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 1:3235 HELMEL CT
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-8113
Mailing Address - Country:US
Mailing Address - Phone:352-596-3032
Mailing Address - Fax:352-596-3066
Practice Address - Street 1:3235 HELMEL CT
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-8113
Practice Address - Country:US
Practice Address - Phone:352-596-3032
Practice Address - Fax:352-596-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124872OtherMEDICAID
IL920540043OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)