Provider Demographics
NPI:1467454660
Name:SHAKUN, EDWIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:J
Last Name:SHAKUN
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:PO BOX 771846
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1846
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:1001 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4135
Practice Address - Country:US
Practice Address - Phone:317-888-3508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047025A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01047025BOtherCSR
IN01047025AOtherINDIANA LICENSE
BS3726239OtherDEA
IN01047025AOtherINDIANA LICENSE
BS3726239OtherDEA