Provider Demographics
NPI:1538376728
Name:MADJZOUB, SHIRIN ELENA (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:SHIRIN
Middle Name:ELENA
Last Name:MADJZOUB
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02145
Mailing Address - Country:US
Mailing Address - Phone:734-272-2479
Mailing Address - Fax:
Practice Address - Street 1:300 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145
Practice Address - Country:US
Practice Address - Phone:734-272-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1538376728Medicare UPIN
MA000690001Medicare PIN