Provider Demographics
NPI:1528066255
Name:MUELLER, SHANNON RAY (DPM)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:RAY
Last Name:MUELLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MEDICAL PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5684
Mailing Address - Country:US
Mailing Address - Phone:817-578-8555
Mailing Address - Fax:817-573-6234
Practice Address - Street 1:1201 MEDICAL PLAZA CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5684
Practice Address - Country:US
Practice Address - Phone:817-578-8555
Practice Address - Fax:817-573-6234
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDPM 1659213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162842201Medicaid
TX5117540001Medicare NSC
TXU92779Medicare UPIN
TX8B2298Medicare PIN
TXP00082769Medicare PIN