Provider Demographics
NPI:1215976576
Name:MARGOLIS, SHALOM EUGENE (MD)
Entity type:Individual
Prefix:
First Name:SHALOM
Middle Name:EUGENE
Last Name:MARGOLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 GREENLEY RD
Mailing Address - Street 2:SUITE 911
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5287
Mailing Address - Country:US
Mailing Address - Phone:209-532-0511
Mailing Address - Fax:209-532-6092
Practice Address - Street 1:900 GREENLEY RD
Practice Address - Street 2:SUITE 911
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5287
Practice Address - Country:US
Practice Address - Phone:209-532-0511
Practice Address - Fax:209-532-6092
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C295970Medicaid
CAA33967Medicare UPIN
CAZZZ15423ZMedicare ID - Type Unspecified