Basic Information
| Provider Information | |||||||||
| NPI: | 1114161320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | JAIMIN | ||||||||
| MiddleName: | GIRISH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 10TH ST N STE 3D | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278247146 | ||||||||
| FaxNumber: | 7278247119 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 10TH ST N | ||||||||
| Address2: | SUITE 3D | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278247146 | ||||||||
| FaxNumber: | 7278247119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 36581 | SC | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | ME124469 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 015054700 | 05 | FL | MEDICAID |