Provider Demographics
NPI:1073515474
Name:SHAPIRO, BRYAN ELIOT (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ELIOT
Last Name:SHAPIRO
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 1983
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1983
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2002 12TH AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:405-272-9644
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24408207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE64031Medicare UPIN