Provider Demographics
NPI:1083607584
Name:ZOLO, SHOSHAN P (MD)
Entity Type:Individual
Prefix:
First Name:SHOSHAN
Middle Name:P
Last Name:ZOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1862
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:25631 LITTLE MACK AVE STE 103
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2100
Practice Address - Country:US
Practice Address - Phone:586-443-2333
Practice Address - Fax:586-443-2332
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3470940Medicaid
MIM75620052Medicare ID - Type Unspecified
MI3470940Medicaid