Provider Demographics
NPI:1427071620
Name:SHAH, INDRAVADAN P (MD)
Entity type:Individual
Prefix:DR
First Name:INDRAVADAN
Middle Name:P
Last Name:SHAH
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 1:770 JOHN ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176
Mailing Address - Country:US
Mailing Address - Phone:386-322-2224
Mailing Address - Fax:386-322-2033
Practice Address - Street 1:667 BEVILLE RD
Practice Address - Street 2:STE B
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1952
Practice Address - Country:US
Practice Address - Phone:386-322-2224
Practice Address - Fax:386-322-2033
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
045382Medicare ID - Type Unspecified
FLK1901Medicare ID - Type UnspecifiedGROUP ID
D84796Medicare UPIN