Provider Demographics
NPI:1740251719
Name:SHAFFER, CRAIG (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:SHAFFER
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 1:1200 NORTH VIRGINIA
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979
Mailing Address - Country:US
Mailing Address - Phone:361-552-6721
Mailing Address - Fax:361-552-7463
Practice Address - Street 1:1200 NORTH VIRGINIA
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-552-6721
Practice Address - Fax:361-552-7463
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC21637Medicare UPIN