Provider Demographics
NPI:1548268865
Name:SHAH, PURVIN (DO)
Entity type:Individual
Prefix:
First Name:PURVIN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9802 BAYMEADOWS RD STE 12
Mailing Address - Street 2:PMB # 156
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7987
Mailing Address - Country:US
Mailing Address - Phone:904-435-7993
Mailing Address - Fax:
Practice Address - Street 1:9802 BAYMEADOWS RD STE 12
Practice Address - Street 2:PMB # 156
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7987
Practice Address - Country:US
Practice Address - Phone:904-435-7993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10029207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30149OtherBLUE CROSS BLUE SHIELD
FL278367300Medicaid
FLAD411WMedicare PIN
FLAD411YMedicare PIN
FLAD411ZMedicare PIN
FL30149OtherBLUE CROSS BLUE SHIELD
FL278367300Medicaid