Provider Demographics
NPI:1588775175
Name:SHUNTA, MARK A (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SHUNTA
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 1:499 W NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON HTS
Mailing Address - State:MI
Mailing Address - Zip Code:49444
Mailing Address - Country:US
Mailing Address - Phone:231-733-2685
Mailing Address - Fax:231-737-1236
Practice Address - Street 1:499 W NORTON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON HTS
Practice Address - State:MI
Practice Address - Zip Code:49444
Practice Address - Country:US
Practice Address - Phone:231-733-2685
Practice Address - Fax:231-737-1236
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI945105112Medicaid
MS002766OtherBCBSM
MS002766OtherBCBSM
MI6006320001Medicare UPIN
MI6006320001Medicare NSC