Provider Demographics
NPI:1154315919
Name:SHAVELLE, DAVID MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:SHAVELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3828 SCHAUFELE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-1793
Mailing Address - Country:US
Mailing Address - Phone:657-241-8990
Mailing Address - Fax:714-665-4664
Practice Address - Street 1:3828 SCHAUFELE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-1793
Practice Address - Country:US
Practice Address - Phone:657-241-8990
Practice Address - Fax:714-665-4664
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54834174400000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100430OtherGROUP MEDICAL
CA00A548340Medicaid
CAP00097660OtherMEDICARE RAILROAD
CA1902846306OtherGROUP NPI
CAW14940OtherHARBOR-UCLA FACULTY PRACTICE PLAN, A MEDICAL GROUP INC.
CAW18762OtherGROUP MEDICARE
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDICAL
CAWA54834EMedicare PIN