Provider Demographics
NPI:1255436804
Name:SHAFFER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:7877 PARKWAY DR
Mailing Address - Street 2:SUITE1B
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2000
Mailing Address - Country:US
Mailing Address - Phone:619-461-3717
Mailing Address - Fax:619-461-5663
Practice Address - Street 1:7877 PARKWAY DR
Practice Address - Street 2:SUITE1B
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2000
Practice Address - Country:US
Practice Address - Phone:619-461-3717
Practice Address - Fax:619-461-5663
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42649Medicare ID - Type Unspecified
E42370Medicare UPIN