Provider Demographics
NPI:1730295932
Name:SHAY, MARK A (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:SHAY
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 1:306 8TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-1565
Mailing Address - Country:US
Mailing Address - Phone:727-867-2151
Mailing Address - Fax:727-867-6835
Practice Address - Street 1:306 8TH AVE N
Practice Address - Street 2:
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-1565
Practice Address - Country:US
Practice Address - Phone:727-867-2151
Practice Address - Fax:727-867-6835
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38413500Medicaid
FL38413500Medicaid
FLD57347Medicare UPIN