Provider Demographics
NPI:1740359629
Name:MADAN, SHASHI (MD)
Entity type:Individual
Prefix:DR
First Name:SHASHI
Middle Name:
Last Name:MADAN
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 1:135 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233
Mailing Address - Country:US
Mailing Address - Phone:770-775-7675
Mailing Address - Fax:770-775-7817
Practice Address - Street 1:135 N OAK ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233
Practice Address - Country:US
Practice Address - Phone:770-775-7675
Practice Address - Fax:770-775-7817
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00568554BMedicaid
110245216OtherRAILROAD MEDICARE
11BDHVNMedicare ID - Type Unspecified
GA00568554BMedicaid