Provider Demographics
NPI:1053354050
Name:SHAFER, RONALD MORTON (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:MORTON
Last Name:SHAFER
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 1:3461 BRIDLEWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802
Mailing Address - Country:US
Mailing Address - Phone:812-243-1590
Mailing Address - Fax:812-234-6614
Practice Address - Street 1:3461 BRIDLEWOOD LANE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:812-243-1590
Practice Address - Fax:812-234-6614
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062324A2084P0800X
IN010485602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000481852OtherBCBS
IN200828520AMedicaid
IN000000481852OtherBCBS
IN200828520AMedicaid