Healthcare Provider Details

I. General information

NPI: 1497746341
Provider Name (Legal Business Name): MARY J SHAVER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 CHRISTINA LN STE B
CONWAY AR
72034-7047
US

IV. Provider business mailing address

PO BOX 17930
LITTLE ROCK AR
72222-7930
US

V. Phone/Fax

Practice location:
  • Phone: 501-279-7077
  • Fax: 501-279-3970
Mailing address:
  • Phone: 501-663-0490
  • Fax: 501-663-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberC-8466
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: