Provider Demographics
NPI:1710307731
Name:SHULKIN, ROMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:SHULKIN
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 1:2277-83 CONEY ISLAND AVE
Mailing Address - Street 2:STE 2A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3337
Mailing Address - Country:US
Mailing Address - Phone:718-998-9890
Mailing Address - Fax:718-998-9891
Practice Address - Street 1:2277-83 CONEY ISLAND AVE
Practice Address - Street 2:STE 2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3337
Practice Address - Country:US
Practice Address - Phone:718-998-9890
Practice Address - Fax:718-998-9891
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA260802207L00000X
NY298411208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05731728Medicaid