Provider Demographics
NPI:1992998207
Name:SHANE, ANITA R (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:R
Last Name:SHANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:R
Other - Last Name:SHIRODKAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:871 VENETIA BAY BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-8049
Mailing Address - Country:US
Mailing Address - Phone:941-202-1900
Mailing Address - Fax:941-786-3358
Practice Address - Street 1:871 VENETIA BAY BLVD STE 115
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-8049
Practice Address - Country:US
Practice Address - Phone:941-202-1900
Practice Address - Fax:941-786-3358
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106689207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002586400Medicaid