Provider Demographics
NPI:1225398431
Name:SHAMBAN, LEONID MIRONOVICH (DO)
Entity type:Individual
Prefix:
First Name:LEONID
Middle Name:MIRONOVICH
Last Name:SHAMBAN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3168 SOLUTIONS CENTER BOX 773168
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3001
Mailing Address - Country:US
Mailing Address - Phone:248-680-8000
Mailing Address - Fax:248-680-8030
Practice Address - Street 1:22250 PROVIDENCE DR STE 301A
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6211
Practice Address - Country:US
Practice Address - Phone:248-849-3281
Practice Address - Fax:248-849-5449
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019763207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty