Provider Demographics
NPI:1548229362
Name:SHOOK, DONALD F JR (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:F
Last Name:SHOOK
Suffix:JR
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2479
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-8544
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029258A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN9397470OtherPHCS PID NUMBER
IN000000190099OtherANTHEM PROVIDER NUMBER
IN100231410Medicaid
IN10825941OtherCAQH NUMBER
INSH80514010Medicaid
IN10825941OtherCAQH NUMBER
IN000000190099OtherANTHEM PROVIDER NUMBER
IN815500MMedicare PIN
INC01201Medicare UPIN