Basic Information
Provider Information | |||||||||
NPI: | 1073764577 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUBEY | ||||||||
FirstName: | SHIVAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
Address2: | MANAGED CARE DEPT | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 33805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6368711008 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338054543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636871275 | ||||||||
FaxNumber: | 8632841534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2008 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01070541A | IN | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | ME142635 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.