Healthcare Provider Details

I. General information

NPI: 1033381801
Provider Name (Legal Business Name): MARCUS DODDRIDGE SHAFFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE SUITE 302
CHARLESTON WV
25302-3302
US

IV. Provider business mailing address

830 PENNSYLVANIA AVE 405
CHARLESTON WV
25302-3390
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2950
  • Fax: 304-388-2951
Mailing address:
  • Phone: 304-388-2980
  • Fax: 304-388-2951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number23875
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: