Provider Demographics
NPI:1811183924
Name:TONY SHALLIN, MDPA
Entity type:Organization
Organization Name:TONY SHALLIN, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-930-4275
Mailing Address - Street 1:3613 WILLIAMS DR STE 404
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1370
Mailing Address - Country:US
Mailing Address - Phone:512-930-4275
Mailing Address - Fax:512-930-4093
Practice Address - Street 1:3613 WILLIAMS DR STE 404
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1370
Practice Address - Country:US
Practice Address - Phone:512-930-4275
Practice Address - Fax:512-930-4093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2323207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172700001Medicaid