Provider Demographics
NPI:1265433742
Name:SHANBOM, STEVEN ADAM (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:ADAM
Last Name:SHANBOM
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 1:28747 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0914
Mailing Address - Country:US
Mailing Address - Phone:248-546-2133
Mailing Address - Fax:248-546-6036
Practice Address - Street 1:28747 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0914
Practice Address - Country:US
Practice Address - Phone:248-546-2133
Practice Address - Fax:248-546-6036
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054486207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18-0-63-8385-1OtherBCBS
5888141OtherAETNA
P43246OtherBLUE CARE NETWORK
131574OtherCARECHOICES
MI18-0-63-2464-1OtherBCBS
0980023OtherHEALTH PLUS
F33213Medicare UPIN