Provider Demographics
NPI:1780888107
Name:STANLEY A. SHATSKY, M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:STANLEY A. SHATSKY, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-780-4745
Mailing Address - Street 1:PO BOX 3147
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-0147
Mailing Address - Country:US
Mailing Address - Phone:408-780-4745
Mailing Address - Fax:
Practice Address - Street 1:2550 SAMARITAN DR STE D
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4104
Practice Address - Country:US
Practice Address - Phone:408-780-4745
Practice Address - Fax:408-709-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41499207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03513ZMedicare ID - Type UnspecifiedMEDICARE GROUP #