Provider Demographics
NPI:1568473809
Name:SHEWMAKE, KINZI V (MD)
Entity Type:Individual
Prefix:
First Name:KINZI
Middle Name:V
Last Name:SHEWMAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KINZI
Other - Middle Name:V
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2727 PACES FERRY RD SE STE 1-1100
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6151
Mailing Address - Country:US
Mailing Address - Phone:470-271-3418
Mailing Address - Fax:
Practice Address - Street 1:1301 SIGMAN RD NE STE 230
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:678-609-4912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11012924207Q00000X
GA072928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160187AMedicaid
IN200924280Medicaid
M400019601Medicare UPIN