Provider Demographics
NPI:1477913747
Name:HARTVICKSON, SHAY (MD)
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:
Last Name:HARTVICKSON
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 1:590 MEDICAL CENTER RD.
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:208-208-1808
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 7015 MURPHY LOOP
Practice Address - Street 2:HOOD ARMY AIRFIELD
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-1000
Practice Address - Country:US
Practice Address - Phone:208-208-1808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14729207P00000X
390200000X
NDPT14729208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program