MEDICARE: LARISA SHAGABAYEVA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275111007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA SHAGABAYEVA MD

Provider Business Mailing Address
First Line	:	2237 E 26TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4941
Country	:	US
Telephone Number	:	347-254-4264
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 NW 12TH AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33136-1005
Country	:	US
Telephone Number	:	347-254-4264
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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