Provider Demographics
NPI:1851686505
Name:SHAFFER, STEPHANIE ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:ANN
Last Name:SHAFFER
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 1:425 HUEHL RD
Mailing Address - Street 2:UNIT 13
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2319
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:425 HUEHL RD
Practice Address - Street 2:UNIT 13
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2319
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2108213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338278001Medicaid
TXP01374944OtherRAILROAD MEDICARE
TX338278002Medicaid
TX338278003Medicaid
TX338278002Medicaid
TX363616YR1KMedicare PIN
TX338278003Medicaid