Provider Demographics
NPI:1679964977
Name:SHELBY, IDRIS JAMAL
Entity Type:Individual
Prefix:MR
First Name:IDRIS
Middle Name:JAMAL
Last Name:SHELBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 SAGEBRUSH DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-7559
Mailing Address - Country:US
Mailing Address - Phone:208-794-7964
Mailing Address - Fax:
Practice Address - Street 1:2681 SAGEBRUSH DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-7559
Practice Address - Country:US
Practice Address - Phone:208-794-7964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-1029224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant