Basic Information
| Provider Information | |||||||||
| NPI: | 1780118679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAYDAKOV | ||||||||
| FirstName: | MAXIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897467500 | ||||||||
| FaxNumber: | 9895836955 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 S WASHINGTON AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897467857 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 4301116183 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.