Provider Demographics
NPI:1649236951
Name:SHADDOX, TRUMAN STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:TRUMAN
Middle Name:STEPHEN
Last Name:SHADDOX
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 1:12 E APPLEBY RD
Mailing Address - Street 2:STE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3901
Mailing Address - Country:US
Mailing Address - Phone:479-463-4444
Mailing Address - Fax:479-463-4499
Practice Address - Street 1:12 E APPLEBY RD
Practice Address - Street 2:STE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3901
Practice Address - Country:US
Practice Address - Phone:479-463-4444
Practice Address - Fax:479-463-4499
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-4757208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106393001Medicaid
ARD84328Medicare UPIN
AR54765Medicare ID - Type Unspecified