Provider Demographics
NPI:1639153828
Name:MACHUTA FERNANDES, SHELLEY (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:
Last Name:MACHUTA FERNANDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:MACHUTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1100 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:STE 140
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6012
Mailing Address - Country:US
Mailing Address - Phone:770-292-7000
Mailing Address - Fax:770-292-7002
Practice Address - Street 1:1100 NORTHSIDE FORSYTH DR
Practice Address - Street 2:STE 140
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6012
Practice Address - Country:US
Practice Address - Phone:770-292-7000
Practice Address - Fax:770-292-7002
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0442722085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000929585BMedicaid
GA457240757AMedicaid
GA000929585VMedicaid
GA000929585DMedicaid
GA92BBGCMMedicare PIN
GA511I920014Medicare PIN
GA000929585VMedicaid
GA92BBFVWMedicare PIN