Provider Demographics
NPI:1265477517
Name:SCHULTZ, MARK J (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-739-4510
Practice Address - Street 1:3805 S KANSAS EXPY STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6989
Practice Address - Country:US
Practice Address - Phone:417-269-0269
Practice Address - Fax:417-269-0279
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO105617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1010052219OtherRAILROAD MEDICARE
MO206034001Medicaid
1673OtherCOX HEALTH SYSTEMS
P00242261OtherRAILROAD MEDICARE
257824OtherHEALTHLINK
3422OtherBCBS
004014190Medicare PIN
1010052219OtherRAILROAD MEDICARE
MOD81006Medicare UPIN
002013784Medicare PIN