Provider Demographics
NPI:1356317598
Name:SHAKER, ISSAM (MD)
Entity Type:Individual
Prefix:
First Name:ISSAM
Middle Name:
Last Name:SHAKER
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 1:840 PINE ST STE 510
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7530
Mailing Address - Country:US
Mailing Address - Phone:478-633-8383
Mailing Address - Fax:478-633-8390
Practice Address - Street 1:840 PINE ST STE 510
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7530
Practice Address - Country:US
Practice Address - Phone:478-633-8383
Practice Address - Fax:478-633-8390
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017883208000000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000082519DMedicaid
GA000082519DMedicaid