Provider Demographics
NPI:1053655969
Name:YAKOV D SHAPOSHNIKOV MD, PC
Entity type:Organization
Organization Name:YAKOV D SHAPOSHNIKOV MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YAKOV
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAPOSHNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-737-3337
Mailing Address - Street 1:8617 ROBINSON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5807
Mailing Address - Country:US
Mailing Address - Phone:702-737-3337
Mailing Address - Fax:702-737-3965
Practice Address - Street 1:2020 WELLNESS WAY
Practice Address - Street 2:SUITE 406
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4000
Practice Address - Country:US
Practice Address - Phone:702-737-3337
Practice Address - Fax:702-737-3965
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YAKOV D SHAPOSHNIKOV MD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8002207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019051Medicaid
NV002019051Medicaid
NVV31839Medicare PIN