Provider Demographics
NPI:1932319613
Name:SHAH, MOBIN (MD)
Entity Type:Individual
Prefix:
First Name:MOBIN
Middle Name:
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 1:352 LANGSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8055
Mailing Address - Country:US
Mailing Address - Phone:256-457-4618
Mailing Address - Fax:
Practice Address - Street 1:1255 HIGHWAY 54 W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4526
Practice Address - Country:US
Practice Address - Phone:770-719-5609
Practice Address - Fax:770-719-5629
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64068207Q00000X, 207R00000X, 208M00000X
GA064068208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102317534Medicaid
MD953138OtherCAREFIRST MD BCBS
PA2109320OtherHIGHMARK BLUE SHIELD
PA2109320OtherHIGHMARK BLUE SHIELD