Provider Demographics
NPI:1982638466
Name:SHELINE, MARTIN ENGWALL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ENGWALL
Last Name:SHELINE
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:P.O. BOX 1770
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32402-1770
Mailing Address - Country:US
Mailing Address - Phone:850-747-4905
Mailing Address - Fax:850-747-4907
Practice Address - Street 1:527 N. PALO ALTO AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3639
Practice Address - Country:US
Practice Address - Phone:850-747-4905
Practice Address - Fax:850-747-4907
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA347102085R0204X
FLME1090932085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003672200Medicaid
FL14E53OtherBCBS
FL003672200Medicaid
FLFA539Medicare PIN