Provider Demographics
NPI:1255391363
Name:SHAFER, ROGER D (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:SHAFER
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 1:300 N GRANDVIEW AVE UPPR LEVEL
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6360
Mailing Address - Country:US
Mailing Address - Phone:563-589-2529
Mailing Address - Fax:563-589-2686
Practice Address - Street 1:300 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6360
Practice Address - Country:US
Practice Address - Phone:563-589-2529
Practice Address - Fax:563-589-2686
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA173172084P0800X
IAMD-173172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0219782Medicaid
IA0219782Medicaid
IA10550Medicare ID - Type UnspecifiedIOWA PROVIDER NUMBER
IAI0550Medicare PIN