Provider Demographics
NPI:1003887183
Name:MAZUMDAR, SHUBHANG N (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUBHANG
Middle Name:N
Last Name:MAZUMDAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-653-3800
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191
Practice Address - Country:US
Practice Address - Phone:702-653-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42826207R00000X
GA19297207R00000X
IN01066467A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000266791BMedicaid
GAD30163Medicare UPIN
PA276446Medicare PIN
GA110229650Medicare PIN
GAGRP2975Medicare PIN
GA000266791BMedicaid