Provider Demographics
NPI:1326001975
Name:HARTLEY, SHIRLEY FRED (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:FRED
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:S
Other - Middle Name:F
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:112 W PASADENA BLVD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-4870
Mailing Address - Country:US
Mailing Address - Phone:281-479-5311
Mailing Address - Fax:281-479-0748
Practice Address - Street 1:112 W PASADENA BLVD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-4870
Practice Address - Country:US
Practice Address - Phone:281-479-5311
Practice Address - Fax:281-479-0748
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0691213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82J977OtherBC/BS OF TEXAS
TX10014888OtherAMERIGROUP NUMBER
TX4250488OtherAETNA PROVIDER NUMBER
TX82J977OtherBC/BS OF TEXAS
TX10014888OtherAMERIGROUP NUMBER
TX82J977Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER