Healthcare Provider Details

I. General information

NPI: 1346207487
Provider Name (Legal Business Name): JEFFREY E SHOOK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HOSPITAL DR
LOGAN WV
25601-3452
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 304-831-1530
  • Fax: 304-831-1527
Mailing address:
  • Phone: 740-446-5890
  • Fax: 740-446-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00315
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.002904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: