Provider Demographics
NPI:1881905164
Name:SHULDBERG, MARK MILLER (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:MILLER
Last Name:SHULDBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1402 S GRAND BLVD
Mailing Address - Street 2:PATHOLOGY
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-577-8782
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-577-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013010528207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology