Provider Demographics
NPI:1558366153
Name:SHAFFER, CARRIE (DO)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 E PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9113
Mailing Address - Country:US
Mailing Address - Phone:219-776-1282
Mailing Address - Fax:
Practice Address - Street 1:425 CALIFORNIA ST STE 1400
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-2116
Practice Address - Country:US
Practice Address - Phone:219-776-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4135207Q00000X
MO2025023431207Q00000X
TN6346207Q00000X
IN02002783A207Q00000X
GA104692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000717646OtherANTHEM TRADITIONAL
IN200497510Medicaid
INI22193Medicare UPIN
IN200497510Medicaid