Provider Demographics
NPI:1164928545
Name:BLACK, SHANEKKIA (MD)
Entity Type:Individual
Prefix:
First Name:SHANEKKIA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 MULKEY RD STE 220
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1127
Mailing Address - Country:US
Mailing Address - Phone:470-956-3760
Mailing Address - Fax:678-398-1930
Practice Address - Street 1:1605 MULKEY RD STE 220
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1127
Practice Address - Country:US
Practice Address - Phone:470-956-3760
Practice Address - Fax:678-398-1930
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA89381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program