Provider Demographics
NPI:1497892061
Name:SHAKER, CHANDRA R (MD, FAAP)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:R
Last Name:SHAKER
Suffix:
Gender:M
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 STURGES AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2399
Mailing Address - Country:US
Mailing Address - Phone:419-522-5454
Mailing Address - Fax:419-522-2981
Practice Address - Street 1:120 STURGES AVE STE 1
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2399
Practice Address - Country:US
Practice Address - Phone:419-522-5454
Practice Address - Fax:419-522-2981
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042404S208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0370781Medicaid
OH0370781Medicaid
OHC46419Medicare UPIN