Provider Demographics
NPI:1275520371
Name:SHULMAN, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SHULMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 MANERA VENTOSA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3663
Mailing Address - Country:US
Mailing Address - Phone:413-813-9539
Mailing Address - Fax:
Practice Address - Street 1:1414 MANERA VENTOSA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-3663
Practice Address - Country:US
Practice Address - Phone:413-813-9539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36884207L00000X
CAG036884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3043118Medicaid
A46849Medicare UPIN
MAJ06892Medicare PIN