Healthcare Provider Details

I. General information

NPI: 1588652408
Provider Name (Legal Business Name): ROBERT MARK SHIDELER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGOW 101 BODIN CIRCLE
TRAVIS AIR FORCE BASE CA
94533
US

IV. Provider business mailing address

60 MDG/SGOW 101 BODIN CIRCLE
TRAVIS AIR FORCE BASE CA
94533
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5174
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01051251A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01051251A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: