Provider Demographics
NPI:1740217348
Name:SHAPIRO, MARC RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:RANDALL
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 EMERSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9529
Mailing Address - Country:US
Mailing Address - Phone:707-994-7241
Mailing Address - Fax:707-994-0870
Practice Address - Street 1:3400 EMERSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9529
Practice Address - Country:US
Practice Address - Phone:707-994-7241
Practice Address - Fax:707-994-0870
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG343590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110222799OtherMEDICARE RAILROAD #
CA00G343590Medicaid
CAP00730930OtherMEDICARE RAILROAD
CABS525Medicare PIN
CA00G343590Medicaid