Provider Demographics
NPI:1457464356
Name:SHILLER, ALAN DALE (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DALE
Last Name:SHILLER
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 1:3323 S LOOP 256
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-6977
Mailing Address - Country:US
Mailing Address - Phone:903-723-1010
Mailing Address - Fax:903-723-0314
Practice Address - Street 1:3323 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6977
Practice Address - Country:US
Practice Address - Phone:903-723-1010
Practice Address - Fax:903-723-0314
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8398207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126630605Medicaid
TX8J8980OtherBLUECROSS/BLUESHIELD
TX8A2909Medicare ID - Type Unspecified
TX126630605Medicaid