Provider Demographics
NPI:1871280339
Name:SHAHSAMAND, ALI (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:SHAHSAMAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PORT CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0526
Mailing Address - Country:US
Mailing Address - Phone:443-929-0357
Mailing Address - Fax:
Practice Address - Street 1:4225 W 20TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5826
Practice Address - Country:US
Practice Address - Phone:786-828-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program