Healthcare Provider Details

I. General information

NPI: 1316131998
Provider Name (Legal Business Name): BRIAN DAVID SHAFER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR STE 3A
KINGSPORT TN
37660-3365
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6200
  • Fax: 423-392-6593
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2009-01336
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberDO2151
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: