Healthcare Provider Details

I. General information

NPI: 1831151869
Provider Name (Legal Business Name): SHAWN E KIDDER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/07/2023
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 DUBOIS DRIVE NULL
WARSAW IN
46580-3212
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 3
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 574-371-2625
  • Fax:
Mailing address:
  • Phone: 260-373-9700
  • Fax: 260-373-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberIN02001281
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: