Organization
DR. MICHAEL C. SHULKIN,OD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL CHARLES SHULKIN O.D. (OWNER)
(707) 542-3404
Entity
Organization
Contact information
Practice address
1188 MONTGOMERY DR, SANTA ROSA, CA 95405-4802
(707) 542-3404
(707) 542-3404
Mailing address
1188 MONTGOMERY DR, SANTA ROSA, CA 95405-4802
(707) 542-3404
(707) 542-3404
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
OPT77030TPA
CA
261QP2300X
Primary Care Clinic/Center
Primary
OPT77030TPA
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00365795
MEDICARE RAILROAD CARRIER
CA
05
—
SD0077030
—
CA
01
—
ZZZ03669Z
MEDICARE (INCORPORATED)
CA
Enumeration date
12/26/2007
Last updated
03/27/2008
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