Provider Demographics
NPI:1407037211
Name:VICTOR A. SHADA, D.O., P.C.
Entity type:Organization
Organization Name:VICTOR A. SHADA, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SHADA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:931-484-4560
Mailing Address - Street 1:PO BOX 887
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-0887
Mailing Address - Country:US
Mailing Address - Phone:931-484-4560
Mailing Address - Fax:931-484-1480
Practice Address - Street 1:396 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5092
Practice Address - Country:US
Practice Address - Phone:931-484-4560
Practice Address - Fax:931-484-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3306875Medicaid
TN3306875Medicaid
TNG94880Medicare UPIN