Provider Demographics
NPI:1538211958
Name:SHULMAN, MARTIN M (OD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:M
Last Name:SHULMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WEST PITMAN ST
Mailing Address - Street 2:
Mailing Address - City:OFALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366
Mailing Address - Country:US
Mailing Address - Phone:636-272-3383
Mailing Address - Fax:636-272-3381
Practice Address - Street 1:100 W PITMAN ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2819
Practice Address - Country:US
Practice Address - Phone:636-272-3383
Practice Address - Fax:636-272-3381
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310754213Medicaid
MO310754213Medicaid