Provider Demographics
NPI:1013933407
Name:HOLDEN, SHAUN B (MD)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:B
Last Name:HOLDEN
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 1:2820 E. ROCK HAVEN RD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-2082
Mailing Address - Country:US
Mailing Address - Phone:816-380-3582
Mailing Address - Fax:816-380-6964
Practice Address - Street 1:2820 E. ROCK HAVEN RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-2082
Practice Address - Country:US
Practice Address - Phone:816-380-3582
Practice Address - Fax:816-380-6964
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD108198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208109603Medicaid
MO22312013OtherBLUE CROSS BLUE SHIELD
5018116OtherAETNA
MO208109603Medicaid
MO080176927Medicare PIN
MO22312013OtherBLUE CROSS BLUE SHIELD
MOF41890Medicare UPIN