Healthcare Provider Details

I. General information

NPI: 1164048534
Provider Name (Legal Business Name): STEVEN WILLIAM SHADER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 08/31/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

802 AZALEA AVE
SAN MARCOS CA
92078-5371
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1288
  • Fax:
Mailing address:
  • Phone: 520-269-1920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: