Provider Demographics
NPI:1467728345
Name:AMDUR, SHIRA (MD)
Entity Type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:AMDUR
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 1:3950 AUSTELL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1121
Mailing Address - Country:US
Mailing Address - Phone:770-793-7899
Mailing Address - Fax:
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-793-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5963207R00000X, 207RH0002X
GA82667207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363246501Medicaid
TX363246501Medicaid
TX531293YKTUMedicare PIN
TX531293YKTXMedicare PIN