MEDICARE: DR. DAVID MARK SHAVELLE M.D.

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	174400000X	Specialist	A54834	CA
2	207RC0000X	Cardiovascular Disease Physician	A54834	CA
3	207RI0011X	Interventional Cardiology Physician	A54834	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00097660	OTHER	CA	MEDICARE RAILROAD
6	W18762	OTHER	CA	GROUP MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0100430	OTHER	CA	GROUP MEDICAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	1902846306	OTHER	CA	GROUP NPI
5	W14940	OTHER	CA	HARBOR-UCLA FACULTY PRACTICE PLAN, A MEDICAL GROUP INC.

General Provider Information

NPI Number	:	1154315919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID MARK SHAVELLE M.D.

Provider Business Mailing Address
First Line	:	3828 SCHAUFELE AVE STE 200
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1793
Country	:	US
Telephone Number	:	657-241-8990
Fax Number	:	714-665-4664

Provider Business Practice Location Address
First Line	:	3828 SCHAUFELE AVE STE 200
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1793
Country	:	US
Telephone Number	:	657-241-8990
Fax Number	:	714-665-4664

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

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	07/17/2020

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