Provider Demographics
NPI:1023015146
Name:SHAFFER, MARK WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513B GREAT OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-8211
Mailing Address - Country:US
Mailing Address - Phone:770-267-9391
Mailing Address - Fax:770-207-7196
Practice Address - Street 1:513B GREAT OAKS DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-8211
Practice Address - Country:US
Practice Address - Phone:770-267-9391
Practice Address - Fax:770-207-7196
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000585213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00401497BMedicaid
GA00401497CMedicaid
GA1396923942Medicare NSC
GA48SCBCDMedicare PIN
GA00401497BMedicaid
GA00401497CMedicaid