Provider Demographics
NPI:1972602902
Name:TRASK, SHAWN D (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:D
Last Name:TRASK
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 1:8104 SEATON PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-7204
Mailing Address - Country:US
Mailing Address - Phone:334-272-3889
Mailing Address - Fax:334-272-4089
Practice Address - Street 1:8104 SEATON PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-7204
Practice Address - Country:US
Practice Address - Phone:334-272-3889
Practice Address - Fax:334-272-4089
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP873208000000X
TN20926208000000X
AL33419208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100095850 INDIVIDUAMedicaid
TN3056158Medicaid
AL180920Medicaid
KY65927394 GROUPMedicaid
KY65927394 GROUPMedicaid
TN3056159Medicare PIN
TNF35002Medicare UPIN