Provider Demographics
NPI:1972581635
Name:SHAFER, HEATHER I L (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:I L
Last Name:SHAFER
Suffix:
Gender:F
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:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:10 JONES RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055
Practice Address - Country:US
Practice Address - Phone:603-672-7600
Practice Address - Fax:603-672-6274
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13329207QS0010X, 207Q00000X, 207QS0010X
MN46857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074468Medicaid
MN914646600Medicaid
MN914646600Medicaid
NH000617701Medicare PIN
MN080013447Medicare PIN