Provider Demographics
NPI:1578727251
Name:SHASTUN, RADISLAV
Entity Type:Individual
Prefix:
First Name:RADISLAV
Middle Name:
Last Name:SHASTUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 NOTTINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:908-686-3570
Mailing Address - Fax:917-829-2009
Practice Address - Street 1:355 NOTTINGHAM WAY
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7932
Practice Address - Country:US
Practice Address - Phone:908-686-3570
Practice Address - Fax:917-829-2009
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYO000109-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist