Healthcare Provider Details

I. General information

NPI: 1821128927
Provider Name (Legal Business Name): J TERESA SHELBY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12250 SW 2ND ST
BEAVERTON OR
97005-2828
US

IV. Provider business mailing address

12250 SW 2ND ST
BEAVERTON OR
97005-2828
US

V. Phone/Fax

Practice location:
  • Phone: 503-641-5596
  • Fax: 503-520-9114
Mailing address:
  • Phone: 503-641-5596
  • Fax: 503-520-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD12000
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: