MEDICARE: DR. CLIFFORD JAMES SHULTZ 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	207Q00000X	Family Medicine Physician	01019249A	IN

General Provider Information

NPI Number	:	1932536083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFFORD JAMES SHULTZ MD

Provider Business Mailing Address
First Line	:	2616 COVINGTON POINTE TRL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2773
Country	:	US
Telephone Number	:	260-432-3366
Fax Number	:

Provider Business Practice Location Address
First Line	:	2616 COVINGTON POINTE TRL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2773
Country	:	US
Telephone Number	:	260-432-3366
Fax Number	:

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

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	10/03/2013

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