Provider Demographics
NPI:1114185840
Name:RUFFIN, SHOMARI ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:SHOMARI
Middle Name:ANDRE
Last Name:RUFFIN
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 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:770-834-0873
Mailing Address - Fax:770-834-6118
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:770-834-6118
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72107207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAREF000630555Medicaid