Healthcare Provider Details

I. General information

NPI: 1992811046
Provider Name (Legal Business Name): CALLIE E SHAFFER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 NEWCOMB AVE
MOUNT VERNON KY
40456-2728
US

IV. Provider business mailing address

PO BOX 1525
MOUNT VERNON KY
40456-1525
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-4148
  • Fax: 606-256-7785
Mailing address:
  • Phone: 606-256-4148
  • Fax: 606-256-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number38737
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: