Provider Demographics
NPI:1780620963
Name:POWELL, RICHARD SHAW (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SHAW
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:910 OAKFIELD DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4925
Mailing Address - Country:US
Mailing Address - Phone:813-681-4413
Mailing Address - Fax:813-684-7299
Practice Address - Street 1:910 OAKFIELD DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4925
Practice Address - Country:US
Practice Address - Phone:813-681-4413
Practice Address - Fax:813-684-7299
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39079207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068489900Medicaid
FL1780620963OtherNPPES
FL068489900Medicaid
FL30663ZMedicare PIN