Provider Demographics
NPI:1912379322
Name:SHAUN KRETZSCHMAR DO PA
Entity Type:Organization
Organization Name:SHAUN KRETZSCHMAR DO PA
Other - Org Name:ALEDO FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:HARDING
Authorized Official - Last Name:KRETZSCHMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-614-6878
Mailing Address - Street 1:317 N FM 1187
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-4200
Mailing Address - Country:US
Mailing Address - Phone:817-441-7181
Mailing Address - Fax:817-441-7893
Practice Address - Street 1:317 N FM 1187
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:TX
Practice Address - Zip Code:76008-4200
Practice Address - Country:US
Practice Address - Phone:817-441-7181
Practice Address - Fax:817-441-7893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAUN KRETZSCHMAR DO PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-25
Last Update Date:2015-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9140207Q00000X
TXJ1940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty