Provider Demographics
NPI:1356851562
Name:SHAKHMATOV, MIKHAIL (MD)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:SHAKHMATOV
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 1:4371 NARROW LANE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2975
Mailing Address - Country:US
Mailing Address - Phone:334-613-3680
Mailing Address - Fax:334-613-3685
Practice Address - Street 1:4371 NARROW LANE RD STE 100
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2975
Practice Address - Country:US
Practice Address - Phone:334-613-3680
Practice Address - Fax:334-613-3685
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL.4599390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program