Provider Demographics
NPI:1639145659
Name:SHPAK, MIKHAIL M (DO)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:M
Last Name:SHPAK
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 1:2064 CROPSEY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6253
Mailing Address - Country:US
Mailing Address - Phone:718-975-8765
Mailing Address - Fax:718-975-8764
Practice Address - Street 1:2064 CROPSEY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-6253
Practice Address - Country:US
Practice Address - Phone:718-975-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231226207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02610608Medicaid
NY02610608Medicaid
5036G1Medicare ID - Type Unspecified