Provider Demographics
NPI:1639202120
Name:SHAH, INDRA C
Entity Type:Individual
Prefix:DR
First Name:INDRA
Middle Name:C
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:INDRAVADAN
Other - Middle Name:C
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:601 OLD NORCROSS RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4311
Mailing Address - Country:US
Mailing Address - Phone:770-963-2474
Mailing Address - Fax:770-963-2476
Practice Address - Street 1:601 OLD NORCROSS RD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4311
Practice Address - Country:US
Practice Address - Phone:770-963-2474
Practice Address - Fax:770-963-2476
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA23224OtherMD LICENSE
GA23224OtherMD LICENSE