Provider Demographics
NPI:1558387753
Name:SHULAK, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:SHULAK
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 1:1101 W UNIVERSITY DR
Mailing Address - Street 2:RADIOLOGY DEPT
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1863
Mailing Address - Country:US
Mailing Address - Phone:248-652-5325
Mailing Address - Fax:248-652-9731
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5325
Practice Address - Fax:248-652-9731
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0540262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF36447009Medicaid
MIF36447009Medicaid
F36447009Medicare ID - Type Unspecified