Provider Demographics
NPI:1366422982
Name:SHIDELER, STEPHEN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:SHIDELER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5210 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4518
Mailing Address - Country:US
Mailing Address - Phone:813-882-9986
Mailing Address - Fax:813-341-3259
Practice Address - Street 1:6600 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-9037
Practice Address - Country:US
Practice Address - Phone:941-800-5001
Practice Address - Fax:941-800-5012
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME138861207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28302Medicare UPIN
IN187490BMedicare PIN
IN100062390AMedicaid