Provider Demographics
NPI:1023404258
Name:SHIVERS, TRAVIS (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SHIVERS
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 1:1000 BEE TEE LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37146-7113
Mailing Address - Country:US
Mailing Address - Phone:615-434-5564
Mailing Address - Fax:217-759-2243
Practice Address - Street 1:1000 BEE TEE LN
Practice Address - Street 2:
Practice Address - City:PLEASANT VIEW
Practice Address - State:TN
Practice Address - Zip Code:37146-7113
Practice Address - Country:US
Practice Address - Phone:615-434-5564
Practice Address - Fax:217-759-2243
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN55498207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035950Medicaid