Provider Demographics
NPI:1457318933
Name:PEFFALL, SHAWN M (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:M
Last Name:PEFFALL
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:PO BOX 62026
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2026
Mailing Address - Country:US
Mailing Address - Phone:410-659-1553
Mailing Address - Fax:
Practice Address - Street 1:7602 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4088
Practice Address - Country:US
Practice Address - Phone:410-663-8100
Practice Address - Fax:410-663-8119
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKF68/610285-01OtherBC/BS
MD970101005Medicaid
MDH32441Medicare UPIN
MDKF68/610285-01OtherBC/BS