Provider Demographics
NPI:1386632735
Name:SHADLE, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:SHADLE
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 1:4682 MCDERMOTT RD # 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7772
Mailing Address - Country:US
Mailing Address - Phone:972-596-6400
Mailing Address - Fax:972-867-4766
Practice Address - Street 1:4682 MCDERMOTT RD # 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-7772
Practice Address - Country:US
Practice Address - Phone:972-596-6400
Practice Address - Fax:972-867-4766
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8L13754Medicare PIN
TXH25519Medicare UPIN