Provider Demographics
NPI:1902880362
Name:SHANDS, COURTNEY III (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:
Last Name:SHANDS
Suffix:III
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 1:12855 N 40 DR
Mailing Address - Street 2:SUITE 375
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8635
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:314-567-7961
Practice Address - Street 1:12855 N 40 DR
Practice Address - Street 2:SUITE 375
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8635
Practice Address - Country:US
Practice Address - Phone:314-567-6071
Practice Address - Fax:314-567-7961
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077041208800000X
MOR3H93208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL05956Medicare PIN
MOA10754Medicare UPIN