Provider Demographics
NPI:1215381710
Name:SHAH, RAVI SURESH (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:SURESH
Last Name:SHAH
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:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0027
Mailing Address - Country:US
Mailing Address - Phone:770-931-1333
Mailing Address - Fax:770-931-3111
Practice Address - Street 1:1235 INDIAN TRAIL LILBURN RD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5524
Practice Address - Country:US
Practice Address - Phone:770-931-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine