Provider Demographics
NPI:1396765558
Name:SHAPIRO, JED SICKLES (MD)
Entity type:Individual
Prefix:DR
First Name:JED
Middle Name:SICKLES
Last Name:SHAPIRO
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 1:888 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-7409
Mailing Address - Country:US
Mailing Address - Phone:303-654-7330
Mailing Address - Fax:
Practice Address - Street 1:1634 WALNUT ST STE 201
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5400
Practice Address - Country:US
Practice Address - Phone:303-654-7330
Practice Address - Fax:303-440-6244
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO198912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01198910Medicaid
CO01198910Medicaid
C23019Medicare ID - Type Unspecified