Provider Demographics
NPI:1851654933
Name:RAZDAN, SHANTANU N (MD)
Entity Type:Individual
Prefix:
First Name:SHANTANU
Middle Name:N
Last Name:RAZDAN
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 1:506 LENOX AVE
Mailing Address - Street 2:MLK 11-101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-1641
Mailing Address - Fax:
Practice Address - Street 1:193 MAIN ST STE 16
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5647
Practice Address - Country:US
Practice Address - Phone:207-743-2544
Practice Address - Fax:207-743-5863
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD23026208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery