Provider Demographics
NPI:1992811046
Name:SHAFFER, CALLIE E (MD)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:E
Last Name:SHAFFER
Suffix:
Gender:F
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:PO BOX 1525
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-1525
Mailing Address - Country:US
Mailing Address - Phone:606-256-4148
Mailing Address - Fax:606-256-5191
Practice Address - Street 1:140 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456-2728
Practice Address - Country:US
Practice Address - Phone:606-256-4148
Practice Address - Fax:606-256-7785
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY27-0496454OtherTAX ID (EFFECT. 01/01/10)
KY637591OtherANTHEM PIN (EFFECT. 01/01/10)
KY7100081050Medicaid
KY000000337528OtherANTHEM BC/BS
KY1217376OtherCHA
KY38737OtherMEDICAL LICENSE NUMBER
KY64087299Medicaid
KY000000475691OtherDEPT OF LABOR
KY000000475691OtherDEPT OF LABOR
KYBS7882144OtherDEA NUMBER
KY000000337528OtherANTHEM BC/BS
KY61-1064744OtherTAX ID NUMBER
KY7100081050Medicaid