Provider Demographics
NPI:1356878292
Name:NIMJAREANSUK, WAROOT SHAY (DO)
Entity type:Individual
Prefix:
First Name:WAROOT
Middle Name:SHAY
Last Name:NIMJAREANSUK
Suffix:
Gender:M
Credentials:DO
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 112727
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32611-2727
Mailing Address - Country:US
Mailing Address - Phone:352-273-7002
Mailing Address - Fax:352-273-7388
Practice Address - Street 1:701 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7313
Practice Address - Country:US
Practice Address - Phone:352-273-7002
Practice Address - Fax:352-273-7388
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303251207P00000X
FLOS17529207P00000X, 207PS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111181000Medicaid