MEDICARE: DR. MICHAEL C. SHULKIN,OD

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	261Q00000X	Clinic/Center	OPT77030TPA	CA
2	261QP2300X	Primary Care Clinic/Center	OPT77030TPA	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00365795	OTHER	CA	MEDICARE RAILROAD CARRIER
3	ZZZ03669Z	OTHER	CA	MEDICARE (INCORPORATED)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568646610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. MICHAEL C. SHULKIN,OD

Provider Business Mailing Address
First Line	:	1188 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4802
Country	:	US
Telephone Number	:	707-542-3404
Fax Number	:	707-542-3404

Provider Business Practice Location Address
First Line	:	1188 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4802
Country	:	US
Telephone Number	:	707-542-3404
Fax Number	:	707-542-3404

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL CHARLES SHULKIN
Credential	:	O.D.
Telephone Number	:	707-542-3404

Provider Enumeration Date	:	12/26/2007
Last Update Date	:	03/27/2008

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Directions to “DR. MICHAEL C. SHULKIN,OD ” Practice Location

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