Provider Demographics
NPI:1962478636
Name:SHALE, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:M
Last Name:SHALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-4755
Mailing Address - Fax:801-442-0643
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 4835
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-4750
Practice Address - Fax:801-387-4755
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1138207P00000X, 208600000X, 208D00000X
UT8501536-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000078865OtherPTAN