Provider Demographics
NPI:1720208010
Name:DUCHESNE, SHADI (MD)
Entity Type:Individual
Prefix:DR
First Name:SHADI
Middle Name:
Last Name:DUCHESNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 FROSTY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821-8010
Mailing Address - Country:US
Mailing Address - Phone:570-204-0402
Mailing Address - Fax:
Practice Address - Street 1:360 WHITE DEER RUN ROAD
Practice Address - Street 2:
Practice Address - City:ALLENWOOD
Practice Address - State:PA
Practice Address - Zip Code:17810
Practice Address - Country:US
Practice Address - Phone:570-538-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-045866-L2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF31359Medicare UPIN