Provider Demographics
NPI:1043394323
Name:SHAFER, BARRY ISAAC (PT)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:ISAAC
Last Name:SHAFER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90730
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-0730
Mailing Address - Country:US
Mailing Address - Phone:626-795-8051
Mailing Address - Fax:
Practice Address - Street 1:800 S RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3229
Practice Address - Country:US
Practice Address - Phone:626-396-8150
Practice Address - Fax:626-795-7374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22169OtherPT LICENSE
CAWPT22169BMedicare ID - Type Unspecified