1629311840 NPI number — DR. MICHELLE SUSAN SHUKHMAN D.O.

Table of content: DR. MICHELLE SUSAN SHUKHMAN D.O. (NPI 1629311840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629311840 NPI number — DR. MICHELLE SUSAN SHUKHMAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUKHMAN
Provider First Name:
MICHELLE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRUZMAN
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629311840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5525 ETIWANDA AVE
Provider Second Line Business Mailing Address:
SUITE #320
Provider Business Mailing Address City Name:
TARZANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91356-3647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-774-3838
Provider Business Mailing Address Fax Number:
818-774-3839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5525 ETIWANDA AVE
Provider Second Line Business Practice Location Address:
SUITE #320
Provider Business Practice Location Address City Name:
TARZANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91356-3647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-774-3838
Provider Business Practice Location Address Fax Number:
818-774-3839
Provider Enumeration Date:
04/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  20A13754 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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