Provider Demographics
NPI:1003947961
Name:COLE, SHANE PARKER (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:PARKER
Last Name:COLE
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:DEPT 960349
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0349
Mailing Address - Country:US
Mailing Address - Phone:405-844-1830
Mailing Address - Fax:405-341-9217
Practice Address - Street 1:801 INTERSTATE 20 W
Practice Address - Street 2:USMD HOSP -- ER DEPT
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5851
Practice Address - Country:US
Practice Address - Phone:817-472-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL 29020207P00000X
TXTEMP MED LICENSE207P00000X
TXN3571207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00834182OtherRR MCARE THRU AEMA
TX204092502Medicaid
P00791718OtherRR MCARE THRU SAEMA
TX204092501Medicaid
TX8BT331OtherBCBS TX
P00834182OtherRR MCARE THRU AEMA
TX204092501Medicaid