Provider Demographics
NPI:1811280035
Name:HEALTHY SHAPES LLC
Entity type:Organization
Organization Name:HEALTHY SHAPES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CADOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-300-4545
Mailing Address - Street 1:PO BOX 2727
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10760 HICKORY RIDGE RD
Practice Address - Street 2:SUITE 125
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3682
Practice Address - Country:US
Practice Address - Phone:410-300-4545
Practice Address - Fax:443-283-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0051318OtherSTATE LICENSE