Basic Information
Provider Information | |||||||||
NPI: | 1396162426 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEHATA | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | MINA HANY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2995 DREW ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337593012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275321355 | ||||||||
FaxNumber: | 8136352613 | ||||||||
Practice Location | |||||||||
Address1: | 6901 SIMMONS LOOP FL 4 | ||||||||
Address2: |   | ||||||||
City: | RIVERVIEW | ||||||||
State: | FL | ||||||||
PostalCode: | 335789498 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133028388 | ||||||||
FaxNumber: | 8133028453 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2014 | ||||||||
LastUpdateDate: | 10/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 290510 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | ME146807 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | ME146807 | FL | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 108146500 | 05 | FL |   | MEDICAID |