Provider Demographics
NPI:1477673218
Name:SHAFER, DIANE ELAIN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ELAIN
Last Name:SHAFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:114 WEST SECOND AVE.
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-0749
Mailing Address - Country:US
Mailing Address - Phone:304-235-4000
Mailing Address - Fax:304-235-4249
Practice Address - Street 1:114 W 2ND AVE # 749
Practice Address - Street 2:114 WEST SECOND AVE.
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3104
Practice Address - Country:US
Practice Address - Phone:304-235-4000
Practice Address - Fax:304-235-4249
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV12440207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVC34993Medicare ID - Type Unspecified