MEDICARE: MICHAEL C SHULKIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT7703TPA	CA
2	152WC0802X	Corneal and Contact Management Optometrist	OPT7703TPA	CA
3	152WP0200X	Pediatric Optometrist	OPT7703TPA	CA
4	152WS0006X	Sports Vision Optometrist	OPT7703TPA	CA
5	152WV0400X	Vision Therapy Optometrist	OPT7703TPA	CA
6	152WX0102X	Occupational Vision Optometrist	OPT7703TPA	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790893824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL C SHULKIN

Provider Business Mailing Address
First Line	:	1188 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4802
Country	:	US
Telephone Number	:	707-542-3404
Fax Number	:	707-542-3404

Provider Business Practice Location Address
First Line	:	1188 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4802
Country	:	US
Telephone Number	:	707-542-3404
Fax Number	:	707-542-3404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	07/16/2010

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Directions to “ MICHAEL C SHULKIN ” Practice Location

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