Provider Demographics
NPI:1528073491
Name:SHAMILOV, MAASI (MD)
Entity type:Individual
Prefix:
First Name:MAASI
Middle Name:
Last Name:SHAMILOV
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 1:5 STEAD CT
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4121
Mailing Address - Country:US
Mailing Address - Phone:856-489-1630
Mailing Address - Fax:
Practice Address - Street 1:765 E ROUTE 70 BLDG 100-A
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2341
Practice Address - Country:US
Practice Address - Phone:856-983-3900
Practice Address - Fax:856-810-0110
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 650982084P0804X
NJ25MA065098002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7270402Medicaid