Provider Demographics
NPI:1508159781
Name:SHAFFER, IAN ARNOLD (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:ARNOLD
Last Name:SHAFFER
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 1:3831 MOSSY OAK DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3836
Mailing Address - Country:US
Mailing Address - Phone:703-304-7712
Mailing Address - Fax:
Practice Address - Street 1:11303 WALNUT CREEK CT
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-2044
Practice Address - Country:US
Practice Address - Phone:703-218-3667
Practice Address - Fax:703-218-3668
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010477802084A0401X, 2084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry