Provider Demographics
NPI:1275572398
Name:SHADID, EDWARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:SHADID
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 1:5900 MOSTELLER DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-840-5100
Mailing Address - Fax:405-840-5102
Practice Address - Street 1:5900 MOSTELLER DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112
Practice Address - Country:US
Practice Address - Phone:405-840-5100
Practice Address - Fax:405-840-5102
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22294174400000X
OK24801208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200194770AMedicaid
OK200026630AMedicaid
OK800522169Medicare ID - Type Unspecified
OK200194770AMedicaid