Provider Demographics
NPI:1669675658
Name:SHAH, MANISH GIRISH (MD)
Entity type:Individual
Prefix:
First Name:MANISH
Middle Name:GIRISH
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 1:1231 FOUNDERS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7645
Mailing Address - Country:US
Mailing Address - Phone:706-495-9897
Mailing Address - Fax:
Practice Address - Street 1:1231 FOUNDERS LAKE DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7645
Practice Address - Country:US
Practice Address - Phone:706-495-9897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0992002085R0202X
GA0697082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology