Provider Demographics
NPI:1265401285
Name:SHEN, MARK W (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:SHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1057 MEDICAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3000
Practice Address - Country:US
Practice Address - Phone:573-348-2745
Practice Address - Fax:573-348-8279
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003005211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209035500Medicaid
MO209035500Medicaid
MO903473557Medicare PIN