Basic Information
| Provider Information | |||||||||
| NPI: | 1891790952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SVOBODA | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 NW ELKS DR | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417541150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 NW ELKS DR | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417541150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 41101 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD152419 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 145421800 | 05 | MN | MEDICAID | 500625065 | 05 | OR | MEDICAID | P00958597 | 01 | OR | RAILROAD MEDICARE | OTHER |