Provider Demographics
NPI:1962762930
Name:BELAVILAS, MARYAM SHOGOFA (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:SHOGOFA
Last Name:BELAVILAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5692
Mailing Address - Country:US
Mailing Address - Phone:352-688-0100
Mailing Address - Fax:352-688-1003
Practice Address - Street 1:225 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609
Practice Address - Country:US
Practice Address - Phone:352-688-0100
Practice Address - Fax:352-688-1003
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124322208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics