Provider Demographics
NPI:1386780302
Name:SHAMS, KIUMARS E (MD)
Entity type:Individual
Prefix:DR
First Name:KIUMARS
Middle Name:E
Last Name:SHAMS
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:PO BOX 186
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-0186
Mailing Address - Country:US
Mailing Address - Phone:850-360-4147
Mailing Address - Fax:850-360-4068
Practice Address - Street 1:5389 COTTON ST
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-1739
Practice Address - Country:US
Practice Address - Phone:850-360-4147
Practice Address - Fax:850-360-4068
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME299492084N0400X, 2084P2900X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038295700Medicaid
FL582678372OtherTRICARE
FL79178OtherBCBS FL
FLK6022Medicare ID - Type Unspecified
FL582678372OtherTRICARE