Provider Demographics
NPI:1720382849
Name:SHAVERS, CONSWALLA U (MD)
Entity Type:Individual
Prefix:
First Name:CONSWALLA
Middle Name:U
Last Name:SHAVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONSWALLA
Other - Middle Name:
Other - Last Name:SHAVERS-MCCANTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:207 HAZEL DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1970
Mailing Address - Country:US
Mailing Address - Phone:267-975-9571
Mailing Address - Fax:
Practice Address - Street 1:207 HAZEL DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-1970
Practice Address - Country:US
Practice Address - Phone:267-975-9571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT045857T207R00000X
DEC1-0007808208D00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice