Provider Demographics
NPI:1578894747
Name:SHEA FAMILY MEDICINE
Entity type:Organization
Organization Name:SHEA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-475-0175
Mailing Address - Street 1:5112 W GORE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5909
Mailing Address - Country:US
Mailing Address - Phone:580-699-3900
Mailing Address - Fax:580-699-3901
Practice Address - Street 1:5112 W GORE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5909
Practice Address - Country:US
Practice Address - Phone:580-699-3900
Practice Address - Fax:580-699-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty