Provider Demographics
NPI:1093037087
Name:SHEARER, CARSON (DO)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:SHEARER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5722
Mailing Address - Country:US
Mailing Address - Phone:580-223-3411
Mailing Address - Fax:580-226-6213
Practice Address - Street 1:20 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5722
Practice Address - Country:US
Practice Address - Phone:580-223-3411
Practice Address - Fax:580-226-6213
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5339207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200494610AMedicaid