Provider Demographics
NPI:1336153733
Name:SHAH, KARUNA (DO)
Entity Type:Individual
Prefix:MRS
First Name:KARUNA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 BROCKETT ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:770-787-8200
Mailing Address - Fax:770-787-8228
Practice Address - Street 1:5211 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2671
Practice Address - Country:US
Practice Address - Phone:770-787-8200
Practice Address - Fax:770-787-8228
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0437732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00764497EMedicaid
GA582155150OtherTIN
GA13BDDJTMedicare PIN
GA00764497EMedicaid