Provider Demographics
NPI:1487726881
Name:SHADID, DEREK J (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:SHADID
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 1:13904 QUAILBROOK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1702
Mailing Address - Country:US
Mailing Address - Phone:405-755-4451
Mailing Address - Fax:405-755-6053
Practice Address - Street 1:13904 QUAILBROOK DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1702
Practice Address - Country:US
Practice Address - Phone:405-755-4451
Practice Address - Fax:405-755-6053
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24344174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522073Medicare ID - Type Unspecified
OKI37623Medicare UPIN