Provider Demographics
NPI:1477865848
Name:SHULMAN, MARK A (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SHULMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 KETTNER BLVD
Mailing Address - Street 2:UNIT 11
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2539
Mailing Address - Country:US
Mailing Address - Phone:619-544-1055
Mailing Address - Fax:619-544-1056
Practice Address - Street 1:1601 KETTNER BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2500
Practice Address - Country:US
Practice Address - Phone:619-544-1055
Practice Address - Fax:619-544-1056
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADZ982ZMedicare PIN