Provider Demographics
NPI:1811154909
Name:SHAFFER, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
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 1:17853 STATE ROUTE 31 STE B
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8835
Mailing Address - Country:US
Mailing Address - Phone:937-578-4004
Mailing Address - Fax:
Practice Address - Street 1:17853 STATE ROUTE 31 STE B
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8835
Practice Address - Country:US
Practice Address - Phone:937-578-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-093380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3097983Medicaid
OH3097983Medicaid