Provider Demographics
NPI:1619331147
Name:SHAH, SIDDHARTH KIRIT (MD)
Entity Type:Individual
Prefix:
First Name:SIDDHARTH
Middle Name:KIRIT
Last Name:SHAH
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 1:6360 MABLETON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5210
Mailing Address - Country:US
Mailing Address - Phone:770-948-8600
Mailing Address - Fax:770-944-7900
Practice Address - Street 1:6360 MABLETON PKWY SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-5210
Practice Address - Country:US
Practice Address - Phone:770-948-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA821722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program