Healthcare Provider Details

I. General information

NPI: 1578976981
Provider Name (Legal Business Name): MARAT NADIROVICH SHAMSUTDINOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 11/22/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18040 SHERMAN WAY
RESEDA CA
91335-4631
US

IV. Provider business mailing address

18040 SHERMAN WAY
RESEDA CA
91335-4631
US

V. Phone/Fax

Practice location:
  • Phone: 818-758-1236
  • Fax:
Mailing address:
  • Phone: 818-758-1236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number278379-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD453570
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA136394
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: