Provider Demographics
NPI:1225398431
Name:SHAMBAN, LEONID MIRONOVICH (DO)
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:MIRONOVICH
Last Name:SHAMBAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28963 LITTLE MACK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3017
Mailing Address - Country:US
Mailing Address - Phone:586-447-0228
Mailing Address - Fax:586-498-0707
Practice Address - Street 1:28963 LITTLE MACK AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081
Practice Address - Country:US
Practice Address - Phone:586-447-0700
Practice Address - Fax:586-498-0707
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019763207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty