Individual
JOHNATHON PATRICK SHAFFER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
583 S CLARIZZ BLVD, BLOOMINGTON, IN 47401-5515
(812) 676-4460
(812) 355-4092
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
A167677
CA
2084N0400X
Neurology Physician
Primary
01085483A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001581445
ANTHEM PTAN
IN
01
—
090540643
MEDICARE PTAN
IN
05
—
300053899
—
IN
Enumeration date
04/05/2016
Last updated
07/30/2024
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