Provider Demographics
NPI:1770531865
Name:SHULKIN, MITCHELL SAMUEL (OD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:SAMUEL
Last Name:SHULKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 CARMEL MOUNTAIN RD
Mailing Address - Street 2:SUITE 1313
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4609
Mailing Address - Country:US
Mailing Address - Phone:858-674-1276
Mailing Address - Fax:858-674-6060
Practice Address - Street 1:11835 CARMEL MOUNTAIN RD
Practice Address - Street 2:SUITE 1313
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4609
Practice Address - Country:US
Practice Address - Phone:858-674-1276
Practice Address - Fax:858-674-6060
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA8153T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081530Medicaid
CASD0081530Medicaid
CAOP8153Medicare ID - Type UnspecifiedNHIC
CAT95862Medicare UPIN