Provider Demographics
NPI:1700088846
Name:CRADDOCK, SHALLON TORE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:SHALLON
Middle Name:TORE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 KAUMANA DR
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1316
Mailing Address - Country:US
Mailing Address - Phone:808-315-1519
Mailing Address - Fax:808-935-9259
Practice Address - Street 1:199 ULULANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2930
Practice Address - Country:US
Practice Address - Phone:808-315-1886
Practice Address - Fax:808-935-9259
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7298208000000X
HI17956208000000X
IL036172973208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1574708Medicaid
WI100306322Medicaid
AKK163945Medicare PIN
AKFC1781031OtherDEA