Provider Demographics
NPI:1235154121
Name:SHATLEY, MIRIAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:J
Last Name:SHATLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HERON COVE - FOXBAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8993
Mailing Address - Country:US
Mailing Address - Phone:601-992-7002
Mailing Address - Fax:
Practice Address - Street 1:108 BELLE MEADE POINTE
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-992-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14462207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS14462OtherSTATE MEDICAL LICENSE ##
MS14462OtherSTATE MEDICAL LICENSE ##
MSF82172Medicare UPIN