Provider Demographics
NPI:1972539484
Name:DOCTOR, SHAMOON A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAMOON
Middle Name:A
Last Name:DOCTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N BEDELL AVE
Mailing Address - Street 2:STE A
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840
Mailing Address - Country:US
Mailing Address - Phone:830-765-3153
Mailing Address - Fax:
Practice Address - Street 1:612 N BEDELL AVE
Practice Address - Street 2:STE A
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840
Practice Address - Country:US
Practice Address - Phone:830-765-3153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2437208600000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150283303Medicaid
TXP01314327OtherMEDICARE RR
TX163208501Medicaid
TX150283302Medicaid
TX8B3387Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
TX163208501Medicaid
TX150283303Medicaid
TX030521008OtherTAX ID NUMBER