MEDICARE: DR. VINCENT STEPHEN SHALLOW MD

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	208800000X	Urology Physician	123271	NY
2	208800000X	Urology Physician	A31633	CA
3	208800000X	Urology Physician	MD-16910	HI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2157538	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1770783052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VINCENT STEPHEN SHALLOW MD

Provider Business Mailing Address
First Line	:	2095 LYNX WAY
Second Line	:
City	:	SAN MARCOS
State	:	CA
Zip	:	92078-0905
Country	:	US
Telephone Number	:	760-304-0226
Fax Number	:

Provider Business Practice Location Address
First Line	:	2095 LYNX WAY
Second Line	:
City	:	SAN MARCOS
State	:	CA
Zip	:	92078-0905
Country	:	US
Telephone Number	:	760-304-0226
Fax Number	:

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

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	08/19/2013

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