Basic Information
| Provider Information | |||||||||
| NPI: | 1770685547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEIKH | ||||||||
| FirstName: | MUJTABA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 FRIENDSHIP RD | ||||||||
| Address2: | |||||||||
| City: | BRASELTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305175630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782074200 | ||||||||
| FaxNumber: | 7705334771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 055702 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2928517070E | 05 | GA | MEDICAID | 2928517070F | 05 | GA | MEDICAID | 2928517070D | 05 | GA | MEDICAID | 582117020 | 01 | GA | TRICARE | OTHER | 424145 | 01 | GA | WELLCARE | OTHER | 01191774 | 01 | GA | AMERIGROUP | OTHER | 7955625 | 01 | GA | AETNA | OTHER | 454249 | 01 | GA | WELLCARE | OTHER | 52703777 | 01 | GA | BCBS | OTHER | 530652 | 01 | GA | WELLCARE | OTHER | 2928517070B | 05 | GA | MEDICAID | 2928517070C | 05 | GA | MEDICAID | 424208 | 01 | GA | WELLCARE | OTHER | 454241 | 01 | GA | WELLCARE | OTHER | 4858323 | 01 | GA | CIGNA | OTHER | 582117020018 | 01 | GA | TRICARE | OTHER | 582117020030 | 01 | GA | TRICARE | OTHER | 582117020024 | 01 | GA | TRICARE | OTHER |