1689679292 NPI number — SHONDA YVETTE SHERAN M.D.

Table of content: SHONDA YVETTE SHERAN M.D. (NPI 1689679292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689679292 NPI number — SHONDA YVETTE SHERAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERAN
Provider First Name:
SHONDA
Provider Middle Name:
YVETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PERRY
Provider Other First Name:
SHONDA
Provider Other Middle Name:
Y
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689679292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748817
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-8817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-286-0333
Provider Business Mailing Address Fax Number:
813-286-1806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4321 N MACDILL AVE
Provider Second Line Business Practice Location Address:
SUITE #205
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-961-7440
Provider Business Practice Location Address Fax Number:
813-962-0951
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  ME85370 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 269077200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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