Provider Demographics
NPI:1578976981
Name:SHAMSUTDINOV, MARAT NADIROVICH (MD)
Entity Type:Individual
Prefix:
First Name:MARAT
Middle Name:NADIROVICH
Last Name:SHAMSUTDINOV
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 1:18040 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4631
Mailing Address - Country:US
Mailing Address - Phone:818-758-1236
Mailing Address - Fax:
Practice Address - Street 1:18040 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4631
Practice Address - Country:US
Practice Address - Phone:818-758-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278379-12084P0804X
PAMD4535702084P0804X
390200000X
CAA1363942084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program