Provider Demographics
NPI:1629028709
Name:SHANKMAN, MARK JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:SHANKMAN
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 1:190 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-3012
Mailing Address - Country:US
Mailing Address - Phone:617-332-3584
Mailing Address - Fax:
Practice Address - Street 1:9 HOPE AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2741
Practice Address - Country:US
Practice Address - Phone:617-243-5590
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB74099Medicare UPIN