Provider Demographics
NPI:1386675502
Name:KRETZSCHMAR, SHAUN H (DO)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:H
Last Name:KRETZSCHMAR
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 1:317 N FM ROAD 1187
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-4200
Mailing Address - Country:US
Mailing Address - Phone:817-441-7181
Mailing Address - Fax:817-441-7893
Practice Address - Street 1:317 N FM ROAD 1187
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4200
Practice Address - Country:US
Practice Address - Phone:817-441-7181
Practice Address - Fax:817-441-7893
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG18418Medicare UPIN
TX8D1168Medicare ID - Type Unspecified
TX8D2508Medicare ID - Type Unspecified