Provider Demographics
NPI:1851308225
Name:ZHAO, SHOURONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOURONG
Middle Name:
Last Name:ZHAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHOURONG
Other - Middle Name:'SHAWN'
Other - Last Name:ZHAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11 U RIVERDALE RD
Mailing Address - Street 2:PATHOLOGY DEPT
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274
Mailing Address - Country:US
Mailing Address - Phone:678-423-1550
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE RD SW
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2615
Practice Address - Country:US
Practice Address - Phone:678-423-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058248207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA146707510AMedicaid
GA058248OtherSTATE LICENSE
AL60045007OtherBCBS
AL60105169OtherBCBS
AL60105170OtherBCBS
AL60045007OtherBCBS