Provider Demographics
NPI:1255523213
Name:MISSELDINE, SHAD (MD)
Entity type:Individual
Prefix:
First Name:SHAD
Middle Name:
Last Name:MISSELDINE
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 1:7600 N 15TH ST STE 290
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4336
Mailing Address - Country:US
Mailing Address - Phone:602-312-0855
Mailing Address - Fax:
Practice Address - Street 1:7600 N 15TH ST STE 290
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4336
Practice Address - Country:US
Practice Address - Phone:602-312-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43059207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ539882Medicaid