Provider Demographics
NPI:1356420707
Name:SHAFER, TAMARA R (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:R
Last Name:SHAFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087508A207Q00000X
CODR.0054578207Q00000X
ORMD150694207Q00000X
MO2005021707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205484702Medicaid
OR500623126Medicaid
MO205484702Medicaid
ORI46266Medicare UPIN
OR500623126Medicaid