MEDICARE: MITCHELL SAMUEL SHULKIN O.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	152W00000X	Optometrist	CA8153T	CA

Other Identifiers

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

General Provider Information

NPI Number	:	1770531865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL SAMUEL SHULKIN O.D.

Provider Business Mailing Address
First Line	:	11835 CARMEL MOUNTAIN RD
Second Line	:	SUITE 1313
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4609
Country	:	US
Telephone Number	:	858-674-1276
Fax Number	:	858-674-6060

Provider Business Practice Location Address
First Line	:	11835 CARMEL MOUNTAIN RD
Second Line	:	SUITE 1313
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4609
Country	:	US
Telephone Number	:	858-674-1276
Fax Number	:	858-674-6060

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	01/11/2012

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