Provider Demographics
NPI:1801383120
Name:CHARBENEAU, SHEA (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHEA
Middle Name:
Last Name:CHARBENEAU
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE # NA23
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-2200
Mailing Address - Fax:
Practice Address - Street 1:101 S SAINTS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3082
Practice Address - Country:US
Practice Address - Phone:405-513-8326
Practice Address - Fax:405-513-7739
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK351213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty