Provider Demographics
NPI:1154428795
Name:SHILDT, RICHARD ALLEN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:SHILDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 W CELEBRATE LIFE WAY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3007
Mailing Address - Country:US
Mailing Address - Phone:623-207-3390
Mailing Address - Fax:623-932-8592
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3007
Practice Address - Country:US
Practice Address - Phone:623-207-3390
Practice Address - Fax:623-932-8592
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13485207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100209440BMedicaid
OK100209440BMedicaid