Provider Demographics
NPI:1508196122
Name:SHAO, MICHAEL YUZHOU (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:YUZHOU
Last Name:SHAO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST STE 230
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4764
Practice Address - Country:US
Practice Address - Phone:260-266-4640
Practice Address - Fax:260-266-4638
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117153208600000X, 2086S0129X
IN01092661A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL406120075OtherMEDICARE INDIVIDUAL PTAN
IL036117153Medicaid
IL406120OtherMEDICARE PTAN FOR SCMG