Provider Demographics
NPI:1417901604
Name:KHAWAJA, SHAZIB N (MD)
Entity Type:Individual
Prefix:
First Name:SHAZIB
Middle Name:N
Last Name:KHAWAJA
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 1:119 AMBULANCE DR 202
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:SUITE 401
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-836-9326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058888207RC0000X, 207RI0011X
AL25860207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009949425Medicaid
MS08537330Medicaid
AL51521327OtherBLUE CROSS
FL269454900Medicaid
AL2510927OtherUNITED HEALTH CARE
FL269454900Medicaid
AL009949425Medicaid