Provider Demographics
NPI:1134355233
Name:SHUMWAY, PRESTON WAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:WAYNE
Last Name:SHUMWAY
Suffix:
Gender:M
Credentials:DO
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018171207P00000X, 390200000X
TXP1407207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX750818167015OtherTRICARE
TX304874601Medicaid
TX75-2616977-028OtherTRICARE
TX750818167048OtherTRICARE
TX8DU721OtherBCBS
TX8X8166OtherBCBS
TXP01081613OtherRAIL ROAD
TX304874603Medicaid
TX750818167022OtherTRICARE
TX751976930022OtherTRICARE
TXP01081147OtherRAIL ROAD
TX750818167044OtherTRICARE
TX75-2616977-001OtherTRICARE
TX75-2616977-002OtherTRICARE
TXP01304487OtherRAIL ROAD
TX304874602Medicaid
TX304874604Medicaid
TX751976930005OtherTRICARE
TX8DD750OtherBCBS
TX8DD753OtherBCBS
TX304874601Medicaid
MIP08090093Medicare PIN
TX750818167022OtherTRICARE
TX304874604Medicaid
TXTXB156883Medicare Oscar/Certification
TX750818167048Medicare PIN