Provider Demographics
NPI:1316928070
Name:SHADLE, BENJAMIN D (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:D
Last Name:SHADLE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10470 OLD PLACERVILLE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3 MEDICAL PLAZA
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-773-8750
Practice Address - Fax:916-773-7963
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2016-10-19
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Provider Licenses
StateLicense IDTaxonomies
CAA99595208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN