Basic Information
| Provider Information | |||||||||
| NPI: | 1588652408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIDELER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MDG/SGOW | ||||||||
| Address2: | 101 BODIN CIRCLE | ||||||||
| City: | TRAVIS AIR FORCE BASE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 60 MDG/SGOW | ||||||||
| Address2: | 101 BODIN CIRCLE | ||||||||
| City: | TRAVIS AIR FORCE BASE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074235174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01051251A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X | 01051251A | IN | N | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.