Healthcare Provider Details

I. General information

NPI: 1194766238
Provider Name (Legal Business Name): WILLIAM THOMAS SHULTS I MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 NW 22ND AVE SUITE 200
PORTLAND OR
97210-3057
US

IV. Provider business mailing address

3827 SW 48TH PL
PORTLAND OR
97221-2105
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-8032
  • Fax: 503-413-6937
Mailing address:
  • Phone: 503-292-8285
  • Fax: 503-413-6937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD07886
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: