Provider Demographics
NPI:1811985062
Name:SHADID, GREGORY ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ERNEST
Last Name:SHADID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1213 LEEPER AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1209
Mailing Address - Country:US
Mailing Address - Phone:574-302-8786
Mailing Address - Fax:405-310-4417
Practice Address - Street 1:1213 LEEPER AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1209
Practice Address - Country:US
Practice Address - Phone:574-302-8786
Practice Address - Fax:405-310-4417
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082994A2084P0800X
OKOK205422084P0800X
TXK10562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100228720BMedicaid
OK100522112Medicare ID - Type Unspecified
OK100228720BMedicaid