Provider Demographics
NPI:1336468131
Name:MANAN I SHAH MD PC
Entity Type:Organization
Organization Name:MANAN I SHAH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-868-0101
Mailing Address - Street 1:14 VISION STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620
Mailing Address - Country:US
Mailing Address - Phone:770-868-0101
Mailing Address - Fax:
Practice Address - Street 1:14 VISION STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620
Practice Address - Country:US
Practice Address - Phone:770-868-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58505207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G181075Medicare UPIN