Provider Demographics
NPI:1558376905
Name:SHADLE, DOUGLAS JAMES (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:SHADLE
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 1:425 CROSS ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4872
Mailing Address - Country:US
Mailing Address - Phone:941-639-4248
Mailing Address - Fax:941-639-8002
Practice Address - Street 1:425 CROSS ST
Practice Address - Street 2:SUITE 116
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4872
Practice Address - Country:US
Practice Address - Phone:941-639-4248
Practice Address - Fax:941-639-8002
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME760842084F0202X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD19739OtherHLTH PROF QUAL ASSURANCE
FLME76084OtherDEPT OF HEALTH
WAMD19739OtherHLTH PROF QUAL ASSURANCE