Provider Demographics
NPI:1750493375
Name:FOSTER, SHAD ALAN (DC)
Entity Type:Individual
Prefix:MR
First Name:SHAD
Middle Name:ALAN
Last Name:FOSTER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10963 VAN WERT DECATUR RD
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-9211
Mailing Address - Country:US
Mailing Address - Phone:419-238-6686
Mailing Address - Fax:419-238-6201
Practice Address - Street 1:10963 VAN WERT DECATUR RD
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-9211
Practice Address - Country:US
Practice Address - Phone:419-238-6686
Practice Address - Fax:419-238-6201
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2440111N00000X
IN08002137A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9312811OtherPTAN
OH2527573Medicaid
OHH536771OtherINDIVIDUAL PTAN
OHH536770OtherGROUP PTAN
OH9312811OtherPTAN
OHH536770OtherGROUP PTAN