Provider Demographics
NPI:1427167691
Name:SHAFFER, JOSEPH JACOB (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JACOB
Last Name:SHAFFER
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 1:60 PLATO BLVD E
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1827
Mailing Address - Country:US
Mailing Address - Phone:651-209-1600
Mailing Address - Fax:651-291-9169
Practice Address - Street 1:1215 TOWN CENTRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1033
Practice Address - Country:US
Practice Address - Phone:651-255-3300
Practice Address - Fax:651-255-3450
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42452207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN061605200Medicaid
MN070000598Medicare PIN