Provider Demographics
NPI:1134106040
Name:MOBASSER, SHAPOUR (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAPOUR
Middle Name:
Last Name:MOBASSER
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 1:5780 PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1513
Mailing Address - Country:US
Mailing Address - Phone:404-303-1224
Mailing Address - Fax:404-303-1325
Practice Address - Street 1:11975 MORRIS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4419
Practice Address - Country:US
Practice Address - Phone:770-521-2295
Practice Address - Fax:770-255-0333
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016743174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000117719GMedicaid
GA000117719DMedicaid
GA000117719EMedicaid
GA000117719GMedicaid