Healthcare Provider Details

I. General information

NPI: 1306885371
Provider Name (Legal Business Name): MAKILZHAN SHANMUGAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 MERCY DR NW SUITE 101
CANTON OH
44708-2626
US

IV. Provider business mailing address

1330 MERCY DR NW STE 101
CANTON OH
44708-2624
US

V. Phone/Fax

Practice location:
  • Phone: 330-588-4676
  • Fax: 330-588-4677
Mailing address:
  • Phone: 216-472-2730
  • Fax: 216-472-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-074146
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: