Provider Demographics
NPI:1891702007
Name:SHOEMAKER, RUSSELL L (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:SHOEMAKER
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 1:212 THOMPSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792-2949
Mailing Address - Country:US
Mailing Address - Phone:828-697-3232
Mailing Address - Fax:
Practice Address - Street 1:212 THOMPSON ST STE A
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-2949
Practice Address - Country:US
Practice Address - Phone:828-697-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126W5Medicaid
NC89126W5Medicaid
NCC24935Medicare UPIN