Basic Information
| Provider Information | |||||||||
| NPI: | 1811956071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAFER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 W UNIVERSITY | ||||||||
| Address2: | STE 1 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808330014 | ||||||||
| FaxNumber: | 4808356821 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 W UNIVERSITY | ||||||||
| Address2: | STE 1 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808330014 | ||||||||
| FaxNumber: | 4808356821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 11098 | AZ | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 172015 | 05 | AZ | MEDICAID |