Healthcare Provider Details

I. General information

NPI: 1770567349
Provider Name (Legal Business Name): MARTIN H SHANK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10035 SW 1ST CT
CORAL SPRINGS FL
33071-7346
US

IV. Provider business mailing address

10035 SW 1ST CT
CORAL SPRINGS FL
33071-7346
US

V. Phone/Fax

Practice location:
  • Phone: 561-542-4100
  • Fax: 954-752-8277
Mailing address:
  • Phone: 561-542-4100
  • Fax: 954-752-8277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO1208
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO1208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: