Provider Demographics
NPI:1235373184
Name:MARC R SHAPIRO MEDICAL CORP
Entity Type:Organization
Organization Name:MARC R SHAPIRO MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-994-7241
Mailing Address - Street 1:3400 EMERSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9529
Mailing Address - Country:US
Mailing Address - Phone:707-994-7241
Mailing Address - Fax:707-994-0870
Practice Address - Street 1:3400 EMERSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9529
Practice Address - Country:US
Practice Address - Phone:707-994-7241
Practice Address - Fax:707-994-0870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP1119OtherMEDICARE RAILROAD
CA1235373184Medicaid
CA00G343590Medicare PIN