Healthcare Provider Details

I. General information

NPI: 1225078033
Provider Name (Legal Business Name): FRED IRVIN SHOFF II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103A PLAZA DR
SAINT CLAIRSVILLE OH
43950-9773
US

IV. Provider business mailing address

51719 STATE ROUTE 26
JERUSALEM OH
43747-9728
US

V. Phone/Fax

Practice location:
  • Phone: 740-695-9321
  • Fax: 740-695-6212
Mailing address:
  • Phone: 740-926-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34003936
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: