Provider Demographics
NPI:1720313364
Name:SEETAHAL, SHIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:SEETAHAL
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 1:40124 HIGHWAY 27
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-5905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40124 HIGHWAY 27
Practice Address - Street 2:SUITE 104
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-5905
Practice Address - Country:US
Practice Address - Phone:863-421-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 123621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIK368ZMedicare PIN