Provider Demographics
NPI:1487815403
Name:MAYNARD, SHAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
Last Name:MAYNARD
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 1:5170 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2004
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:304-399-0015
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:ROOM 1025
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-399-7484
Practice Address - Fax:304-399-7579
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24520207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020815Medicaid