Basic Information
Provider Information | |||||||||
NPI: | 1134355233 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHUMWAY | ||||||||
FirstName: | PRESTON | ||||||||
MiddleName: | WAYNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 841656 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752841656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035315000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 E DAWSON ST | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757012036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035315000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2009 | ||||||||
LastUpdateDate: | 10/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101018171 | MI | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 390200000X | 5101018171 | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | P1407 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 750818167015 | 01 | TX | TRICARE | OTHER | 304874601 | 05 | TX |   | MEDICAID | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 750818167048 | 01 | TX | TRICARE | OTHER | 8DU721 | 01 | TX | BCBS | OTHER | 8X8166 | 01 | TX | BCBS | OTHER | P01081613 | 01 | TX | RAIL ROAD | OTHER | 304874603 | 05 | TX |   | MEDICAID | 750818167022 | 01 | TX | TRICARE | OTHER | 751976930022 | 01 | TX | TRICARE | OTHER | P01081147 | 01 | TX | RAIL ROAD | OTHER | 750818167044 | 01 | TX | TRICARE | OTHER | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | P01304487 | 01 | TX | RAIL ROAD | OTHER | 304874602 | 05 | TX |   | MEDICAID | 304874604 | 05 | TX |   | MEDICAID | 751976930005 | 01 | TX | TRICARE | OTHER | 8DD750 | 01 | TX | BCBS | OTHER | 8DD753 | 01 | TX | BCBS | OTHER |