Healthcare Provider Details

I. General information

NPI: 1205331261
Provider Name (Legal Business Name): ILYA YEVGENIEVICH SHADRIN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ILIA YEVGENIEVICH SHADRIN

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN RD # DUMC3845
DURHAM NC
27705-4699
US

IV. Provider business mailing address

2301 ERWIN RD # DUMC3845
DURHAM NC
27705-4699
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-8111
  • Fax:
Mailing address:
  • Phone: 919-684-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2026-03615
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: