Provider Demographics
NPI:1710136825
Name:SHAFFER, MARTIN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:CHARLES
Last Name:SHAFFER
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 1:76915 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-7736
Mailing Address - Country:US
Mailing Address - Phone:760-469-3703
Mailing Address - Fax:
Practice Address - Street 1:76915 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-7736
Practice Address - Country:US
Practice Address - Phone:760-469-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27453208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A91054Medicare UPIN