MEDICARE: JOHN ROBERT SHAKULA 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	208000000X	Pediatrics Physician	1574601205	UT

General Provider Information

NPI Number	:	1235179375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ROBERT SHAKULA M.D.

Provider Business Mailing Address
First Line	:	12801 BOULTER ST
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-9134
Country	:	US
Telephone Number	:	801-571-0423
Fax Number	:	801-571-0081

Provider Business Practice Location Address
First Line	:	9720 S 1300 E
Second Line	:	W120
City	:	SANDY
State	:	UT
Zip	:	84094-3712
Country	:	US
Telephone Number	:	801-571-0423
Fax Number	:	801-571-0081

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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