Healthcare Provider Details

I. General information

NPI: 1598862070
Provider Name (Legal Business Name): DAVID WILLIAM SHOUP D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19389 N 59TH AVE
GLENDALE AZ
85308-6500
US

IV. Provider business mailing address

19555 N 59TH AVE
GLENDALE AZ
85308-6813
US

V. Phone/Fax

Practice location:
  • Phone: 623-537-6000
  • Fax: 623-537-6014
Mailing address:
  • Phone: 623-537-6000
  • Fax: 623-537-6014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberAZ3125
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAZ03125
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: