1215964770 NPI number — THOMAS R SHELOR OD PA

Table of content: THOMAS R SHELOR OD PA (NPI 1215964770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215964770 NPI number — THOMAS R SHELOR OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELOR
Provider First Name:
THOMAS
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215964770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 S CLAIRBORNE RD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
OLATHE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66062-1735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-782-1213
Provider Business Mailing Address Fax Number:
913-782-4801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 S CLAIRBORNE RD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
OLATHE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66062-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-782-1213
Provider Business Practice Location Address Fax Number:
913-782-4801
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1075-2 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4526530001 . This is a "CIGNA MEDICARE DMERC" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 04524021 . This is a "BC BS OF KC" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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