Provider Demographics
NPI:1053301721
Name:SHAFER, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SHAFER
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:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-0206
Mailing Address - Country:US
Mailing Address - Phone:802-365-4354
Mailing Address - Fax:
Practice Address - Street 1:1154 VT ROUTE 30
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353-9724
Practice Address - Country:US
Practice Address - Phone:802-365-4354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D03308Medicare UPIN
VTVN0834Medicare PIN
VT6030Medicare ID - Type Unspecified