Provider Demographics
NPI:1972865384
Name:SHROUDER, JAMES LORAN III (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LORAN
Last Name:SHROUDER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5776
Mailing Address - Country:US
Mailing Address - Phone:904-826-3469
Mailing Address - Fax:904-808-4608
Practice Address - Street 1:130 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5776
Practice Address - Country:US
Practice Address - Phone:904-826-3469
Practice Address - Fax:904-808-4608
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34546207Q00000X
FLME143399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105894900Medicaid
SC345460Medicaid
SCSC62915019OtherMEDICARE PIN