Provider Demographics
NPI:1831375443
Name:TARTT, SHANE RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:RANDALL
Last Name:TARTT
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 1:800 PRUDENTIAL DR
Mailing Address - Street 2:SUITE 606
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:404-824-4987
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:404-824-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101522207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology