Provider Demographics
NPI:1912247719
Name:MATHURA, SHIVA A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:A
Last Name:MATHURA
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 1:110 POND CT STE 203
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2717
Mailing Address - Country:US
Mailing Address - Phone:386-259-4106
Mailing Address - Fax:866-554-1654
Practice Address - Street 1:110 POND CT STE 203
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2717
Practice Address - Country:US
Practice Address - Phone:386-259-4106
Practice Address - Fax:866-554-1654
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine