Healthcare Provider Details

I. General information

NPI: 1922080761
Provider Name (Legal Business Name): MARK CYRIL SHEARS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E PARK AVE
STATE COLLEGE PA
16803-6701
US

IV. Provider business mailing address

PO BOX 197
STATE COLLEGE PA
16804-0197
US

V. Phone/Fax

Practice location:
  • Phone: 814-234-6137
  • Fax: 814-234-6795
Mailing address:
  • Phone: 814-235-1208
  • Fax: 814-235-1566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD035513E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001155770
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: