Healthcare Provider Details

I. General information

NPI: 1760307136
Provider Name (Legal Business Name): SOVEREIGN PALADIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 CENTER DR
LOS ANGELES CA
90045-9209
US

IV. Provider business mailing address

12444 NW 10TH STREET, STE 202 BOX 175
YUKON OK
73099
US

V. Phone/Fax

Practice location:
  • Phone: 424-512-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MARK SHIDELER
Title or Position: CEO OWNER
Credential: MD
Phone: 937-219-8735