Provider Demographics
NPI:1982696878
Name:SHAMSUDDIN, SHAJU (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAJU
Middle Name:
Last Name:SHAMSUDDIN
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 1:667 EASTLAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4503
Mailing Address - Country:US
Mailing Address - Phone:330-841-4126
Mailing Address - Fax:330-841-4598
Practice Address - Street 1:667 EASTLAND AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4503
Practice Address - Country:US
Practice Address - Phone:330-841-4126
Practice Address - Fax:330-841-4598
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062322L2085R0001X
OH35.0699562085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101275823Medicaid
OHH440680OtherMEDICARE PTAN
OH2075301Medicaid
PAG74901Medicare UPIN