Healthcare Provider Details

I. General information

NPI: 1780642702
Provider Name (Legal Business Name): MARK R SHAFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

IV. Provider business mailing address

90 ADELINE RD
NEWTON MA
02459-2705
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-7100
  • Fax:
Mailing address:
  • Phone: 401-273-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number158271
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: