Provider Demographics
NPI:1821053091
Name:SHETLAR, JOHN M (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SHETLAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-1572
Mailing Address - Country:US
Mailing Address - Phone:888-381-4858
Mailing Address - Fax:913-297-9628
Practice Address - Street 1:1100 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1572
Practice Address - Country:US
Practice Address - Phone:888-381-4858
Practice Address - Fax:913-297-9628
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0524233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100162320EMedicaid
KSE78225Medicare UPIN
KS110116048Medicare PIN