Provider Demographics
NPI:1629560032
Name:SHAH, JINEN (OD)
Entity Type:Individual
Prefix:
First Name:JINEN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FERRY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2700
Mailing Address - Country:US
Mailing Address - Phone:678-263-2226
Mailing Address - Fax:678-263-2320
Practice Address - Street 1:1100 JOHNSON FERRY RD STE 120
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2700
Practice Address - Country:US
Practice Address - Phone:678-263-2226
Practice Address - Fax:678-263-2320
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist