Provider Demographics
NPI:1710060017
Name:SHAFFER, KELLY ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ELAINE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:ELAINE
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1300 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3261
Mailing Address - Country:US
Mailing Address - Phone:843-884-9646
Mailing Address - Fax:843-884-9601
Practice Address - Street 1:2687 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9100
Practice Address - Country:US
Practice Address - Phone:843-572-1010
Practice Address - Fax:843-569-1719
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-02041208800000X
SCLL28461208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28461OtherSC MEDICAL LICENSE
NC273905550OtherNC MED BOARD # 153519
2023380BMedicare Oscar/Certification