Provider Demographics
NPI:1588652408
Name:SHIDELER, ROBERT MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARK
Last Name:SHIDELER
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 1:60 MDG/SGOW
Mailing Address - Street 2:101 BODIN CIRCLE
Mailing Address - City:TRAVIS AIR FORCE BASE
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/SGOW
Practice Address - Street 2:101 BODIN CIRCLE
Practice Address - City:TRAVIS AIR FORCE BASE
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-423-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051251A2084P0800X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice