Basic Information
| Provider Information | |||||||||
| NPI: | 1932319613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | MOBIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 352 LANGSHIRE DR | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302538055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564574618 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1255 HIGHWAY 54 W | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707195609 | ||||||||
| FaxNumber: | 7707195629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 64068 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 64068 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 64068 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 064068 | GA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 102317534 | 05 | PA | MEDICAID | 953138 | 01 | MD | CAREFIRST MD BCBS | OTHER | 2109320 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |