Provider Demographics
NPI:1720116452
Name:BALAKUMAR, SHANGEETHA (MD)
Entity Type:Individual
Prefix:
First Name:SHANGEETHA
Middle Name:
Last Name:BALAKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 COBB PKWY S STE 60
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6531
Mailing Address - Country:US
Mailing Address - Phone:678-820-7373
Mailing Address - Fax:
Practice Address - Street 1:280 COBB PKWY S STE 60
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6531
Practice Address - Country:US
Practice Address - Phone:678-820-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105139207Q00000X
SCLL28993207Q00000X
GA83851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002442900Medicaid
FLDJ401ZMedicare PIN