Basic Information
Provider Information | |||||||||
NPI: | 1134106040 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOBASSER | ||||||||
FirstName: | SHAPOUR | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5780 PEACHTREE DUNWOODY ROAD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303421513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043031224 | ||||||||
FaxNumber: | 4043031325 | ||||||||
Practice Location | |||||||||
Address1: | 11975 MORRIS RD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300054419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705212295 | ||||||||
FaxNumber: | 7702550333 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2005 | ||||||||
LastUpdateDate: | 08/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 016743 | GA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 000117719G | 05 | GA |   | MEDICAID | 000117719D | 05 | GA |   | MEDICAID | 000117719E | 05 | GA |   | MEDICAID |