Provider Demographics
NPI:1811214133
Name:SHAH, NEIL
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5605 GLENRIDGE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1365
Mailing Address - Country:US
Mailing Address - Phone:678-553-7783
Mailing Address - Fax:678-553-7793
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-6323
Practice Address - Fax:404-303-3747
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18112141332085R0202X
GA390200000X
GA0738292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program