Provider Demographics
NPI:1124015565
Name:SHANTI, CHRISTINA MUBARAK (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MUBARAK
Last Name:SHANTI
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-9106
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-9106
Practice Address - Fax:313-916-1249
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010702552086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1396817714OtherGROUP NPI
MI4735568Medicaid
MI4864707Medicaid
MI4735577Medicaid
CS070255OtherCOMMERCIAL-COMMERCIAL NUMBER
CS070255OtherCHAMPUS-CHAMPUS
MI1396817714OtherGROUP NPI
CS070255OtherCOMMERCIAL-COMMERCIAL NUMBER