Provider Demographics
NPI:1902839657
Name:SHOCKEY, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:SHOCKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1220 E 3900 S STE 2C
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1319
Mailing Address - Country:US
Mailing Address - Phone:801-263-2482
Mailing Address - Fax:801-263-2424
Practice Address - Street 1:1220 E 3900 S STE 2C
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1319
Practice Address - Country:US
Practice Address - Phone:801-263-2482
Practice Address - Fax:801-263-2424
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT163879-1205207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
QM0000018088OtherALTIUS
107004966101OtherSELECT CARE
870450466SH1OtherEMIA
PR07070OtherMOLINA
1408OtherUNIV OF UTAH
36670OtherDMBA
68893OtherPEHP
36670OtherDMBA