1770937518 NPI number — DR. SHAWN MAHMUD M.D., PH.D.

Table of content: DR. SHAWN MAHMUD M.D., PH.D. (NPI 1770937518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770937518 NPI number — DR. SHAWN MAHMUD M.D., PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHMUD
Provider First Name:
SHAWN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770937518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2450 RIVERSIDE AVE
Provider Second Line Business Mailing Address:
M663 RIVERSIDE EAST BLDG, CDC 8952F
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55454-1450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-624-8903
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2414 S 7TH ST
Provider Second Line Business Practice Location Address:
AO-10 ACADEMIC OFFICE BUILDING
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55454-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-626-4598
Provider Business Practice Location Address Fax Number:
612-626-6905
Provider Enumeration Date:
04/18/2016

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: 2080P0216X , with the licence number:  66389 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1770937518 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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