Provider Demographics
NPI:1386682896
Name:THIEL, SHELLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:
Last Name:THIEL
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:7000 BOULDER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3348
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:909-862-7179
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021929207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
96614OtherL&I
WA1018571Medicaid
WA1018571Medicaid
WAAB08302Medicare PIN