Provider Demographics
NPI:1043392863
Name:GEORGE, SHIRL DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:SHIRL
Middle Name:DOUGLAS
Last Name:GEORGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:DOUGLAS
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 14230
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-4230
Mailing Address - Country:US
Mailing Address - Phone:307-734-1313
Mailing Address - Fax:
Practice Address - Street 1:555 E BROADWAY AVE STE 108
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-734-1313
Practice Address - Fax:307-734-0314
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6199A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114060400Medicaid
WY114060400Medicaid
WY307978Medicare ID - Type UnspecifiedMEDICARE