Provider Demographics
NPI:1619033289
Name:SHAFFER, JOHN BP (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BP
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NO. MAIN ST
Mailing Address - Street 2:STE. 301
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3717
Mailing Address - Country:US
Mailing Address - Phone:845-639-9460
Mailing Address - Fax:914-948-1604
Practice Address - Street 1:120 NO. MAIN ST
Practice Address - Street 2:STE. 301
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3717
Practice Address - Country:US
Practice Address - Phone:845-639-9460
Practice Address - Fax:914-948-1604
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0030911103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
126585000OtherMAGELLAN
145179OtherVALUE OPTIONS
NY01283316Medicaid
P473564OtherOXFORD
NY01283316Medicaid
R50685Medicare UPIN
P473564OtherOXFORD