Basic Information
Provider Information | |||||||||
NPI: | 1548257058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEVITZ | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1901 BUTTERFIELD RD | ||||||||
Address2: | SUITE 220 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605157915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6307252768 | ||||||||
FaxNumber: | 6307252783 | ||||||||
Practice Location | |||||||||
Address1: | 5550 GLADES RD | ||||||||
Address2: | SUITE 210 | ||||||||
City: | BOCA RATON | ||||||||
State: | FL | ||||||||
PostalCode: | 334317205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617502130 | ||||||||
FaxNumber: | 5613676170 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2005 | ||||||||
LastUpdateDate: | 03/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | ME74461 | FL | N |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 207K00000X | 42176 | TN | N |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   | 207P00000X | 2007-00905 | NC | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 202K00000X | ME74461 | NC | Y |   | Allopathic & Osteopathic Physicians | Phlebology |   |
ID Information
ID | Type | State | Issuer | Description | 758992100 | 05 | FL |   | MEDICAID |