Basic Information
| Provider Information | |||||||||
| NPI: | 1134115967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODDER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | SHELNUTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELNUTT DODDER | ||||||||
| OtherFirstName: | AVA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| 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 310 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707520824 | ||||||||
| FaxNumber: | 7707520845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 040784 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 174400000X | 040784 | GA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000795385D | 05 | GA | MEDICAID | 000795385E | 05 | GA | MEDICAID | 000795385F | 05 | GA | MEDICAID |