Provider Demographics
NPI:1346220035
Name:GOUGH-FIBKINS, SHAWN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:EDWARD
Last Name:GOUGH-FIBKINS
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 1:9824 SW 133RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2203
Mailing Address - Country:US
Mailing Address - Phone:305-382-4378
Mailing Address - Fax:
Practice Address - Street 1:9824 SW 133RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-2203
Practice Address - Country:US
Practice Address - Phone:305-382-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 905292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2792796Medicaid
OH2792796Medicaid
PA119201Medicare PIN