Provider Demographics
NPI:1487857892
Name:SEROYER, SHANE T (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:T
Last Name:SEROYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 MATLOCK ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3604
Mailing Address - Country:US
Mailing Address - Phone:817-419-0303
Mailing Address - Fax:817-468-5963
Practice Address - Street 1:3533 MATLOCK ROAD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3604
Practice Address - Country:US
Practice Address - Phone:817-419-0303
Practice Address - Fax:817-468-5963
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1887207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204613801Medicaid
TX8L17117Medicare PIN