1205188430 NPI number — DR. SHEA SPEIGHTS ED. D

Table of content: DR. SHEA SPEIGHTS ED. D (NPI 1205188430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205188430 NPI number — DR. SHEA SPEIGHTS ED. D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPEIGHTS
Provider First Name:
SHEA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED. D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205188430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1503 WARMAN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33613-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-650-7720
Provider Business Mailing Address Fax Number:
813-354-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 W HAMILTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33604-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-650-7720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2012

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 692610098 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 692610096 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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