Provider Demographics
NPI:1669572343
Name:REATHAFORD, SHAWN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:ROBERT
Last Name:REATHAFORD
Suffix:
Gender:
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 7412021
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2021
Mailing Address - Country:US
Mailing Address - Phone:314-535-7855
Mailing Address - Fax:314-534-2803
Practice Address - Street 1:4488 FOREST PARK AVE
Practice Address - Street 2:STE 230
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2283
Practice Address - Country:US
Practice Address - Phone:314-535-7855
Practice Address - Fax:314-534-2803
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170398522080P0204X, 208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200049825Medicaid
K24063Medicare ID - Type Unspecified