Provider Demographics
NPI:1770655987
Name:SHAH, CHANDRESH B (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRESH
Middle Name:B
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 1:4300 MILLSIDE CT SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6396
Mailing Address - Country:US
Mailing Address - Phone:770-333-8657
Mailing Address - Fax:770-333-6230
Practice Address - Street 1:2615 E WEST CONNECTOR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6848
Practice Address - Country:US
Practice Address - Phone:770-941-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000619594CMedicaid
GA000619594CMedicaid
GAF29978Medicare UPIN