Provider Demographics
NPI:1902839913
Name:VRAJESH SHAH M.D., P.A.
Entity Type:Organization
Organization Name:VRAJESH SHAH M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-960-4894
Mailing Address - Street 1:PO BOX 271447
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-1447
Mailing Address - Country:US
Mailing Address - Phone:813-960-4894
Mailing Address - Fax:813-968-4997
Practice Address - Street 1:15953 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-8102
Practice Address - Country:US
Practice Address - Phone:813-960-4894
Practice Address - Fax:813-968-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370821701Medicaid
FL370821701Medicaid
FL18175Medicare PIN