Provider Demographics
NPI:1205803897
Name:ISAEFF, SHAWN DALE (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:DALE
Last Name:ISAEFF
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 1:5974 FASHION POINT DR STE 110
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4712
Mailing Address - Country:US
Mailing Address - Phone:801-917-2270
Mailing Address - Fax:661-200-7783
Practice Address - Street 1:5974 FASHION POINT DR STE 110
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4712
Practice Address - Country:US
Practice Address - Phone:801-917-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC554472085R0204X
TNMD340762085R0202X
OK249142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK247622001OtherMEDICARE
OK200084140AMedicaid
TN3850918Medicaid
OKP00345589OtherRAILROAD MEDICARE
OK247622002OtherMEDICARE
TNH11813Medicare UPIN
OKP00345589OtherRAILROAD MEDICARE