Provider Demographics
NPI:1952638272
Name:CARDOZO, SHAUN (MD)
Entity type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:
Last Name:CARDOZO
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 1:400 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:313-448-9006
Mailing Address - Fax:313-993-7770
Practice Address - Street 1:400 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:313-448-9650
Practice Address - Fax:313-448-9979
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093033207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630770Medicare PIN