Provider Demographics
NPI:1265401020
Name:KASSAM, SHIRAZ HABIB (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRAZ
Middle Name:HABIB
Last Name:KASSAM
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 1:1380 MILSTEAD AVE NE STE B
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3864
Mailing Address - Country:US
Mailing Address - Phone:770-922-2424
Mailing Address - Fax:770-922-8782
Practice Address - Street 1:1380 MILSTEAD AVE NE STE B
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3864
Practice Address - Country:US
Practice Address - Phone:770-922-2424
Practice Address - Fax:770-922-8782
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21321207VG0400X, 207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000190506BMedicaid
GAD29907Medicare UPIN