Provider Demographics
NPI:1912985110
Name:SHRADER, CARL ERNEST JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ERNEST
Last Name:SHRADER
Suffix:JR
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 1:120 W. FINE AVE.
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-773-9695
Mailing Address - Fax:928-773-0208
Practice Address - Street 1:120 W. FINE AVE.
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-9695
Practice Address - Fax:928-773-0208
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121065Medicare UPIN
AZZ120952Medicare PIN
AZD00316Medicare UPIN
AZZ120963Medicare PIN
AZZ133662Medicare UPIN