Healthcare Provider Details

I. General information

NPI: 1356978456
Provider Name (Legal Business Name): MAHMETHAN M SHADID MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N MECKLENBURG AVE
SOUTH HILL VA
23970-4080
US

IV. Provider business mailing address

PO BOX 932909
CLEVELAND OH
44193-2909
US

V. Phone/Fax

Practice location:
  • Phone: 434-584-5540
  • Fax: 434-774-2401
Mailing address:
  • Phone: 330-854-4281
  • Fax: 330-854-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.149844
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101284925
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: