Provider Demographics
NPI:1770567349
Name:SHANK, MARTIN H (DPM)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:H
Last Name:SHANK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10035 SW 1ST CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-7346
Mailing Address - Country:US
Mailing Address - Phone:561-542-4100
Mailing Address - Fax:954-752-8277
Practice Address - Street 1:10035 SW 1ST CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-7346
Practice Address - Country:US
Practice Address - Phone:561-542-4100
Practice Address - Fax:954-752-8277
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1208213E00000X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029776300Medicaid
T95157Medicare UPIN
87615Medicare ID - Type Unspecified
FL029776300Medicaid