Provider Demographics
NPI:1629097472
Name:SHAH, SURESH HIRJI (MD)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:HIRJI
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0027
Mailing Address - Country:US
Mailing Address - Phone:770-931-1333
Mailing Address - Fax:770-931-3111
Practice Address - Street 1:1235 INDIAN TRAIL LILBURN RD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-4502
Practice Address - Country:US
Practice Address - Phone:770-931-1333
Practice Address - Fax:770-931-3111
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA033193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00466958QMedicaid
GA00466958QMedicaid
GA113DTXSMedicare ID - Type Unspecified