Provider Demographics
NPI:1447332424
Name:SHANE, STEPHAN W (DO)
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:W
Last Name:SHANE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-3543
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:859 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-3543
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098583207R00000X
CO47019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26588021Medicaid
CO019392OtherKAISER COMMERCIAL NUMBER
IL036009853Medicaid
COCO302024Medicare PIN
ILL72583Medicare ID - Type UnspecifiedINDIVIDUAL #
IL815990Medicare ID - Type UnspecifiedGROUP #
IL036009853Medicaid
CO26588021Medicaid