Provider Demographics
NPI:1932536083
Name:SHULTZ, CLIFFORD JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:JAMES
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 COVINGTON POINTE TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2773
Mailing Address - Country:US
Mailing Address - Phone:260-432-3366
Mailing Address - Fax:
Practice Address - Street 1:2616 COVINGTON POINTE TRL
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2773
Practice Address - Country:US
Practice Address - Phone:260-432-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019249A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine