Healthcare Provider Details

I. General information

NPI: 1033343439
Provider Name (Legal Business Name): MARISSA SHAMS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 08/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 UPPERGATE DR NE
ATLANTA GA
30322-1015
US

IV. Provider business mailing address

2015 UPPERGATE DR NE
ATLANTA GA
30322-1015
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2400
  • Fax:
Mailing address:
  • Phone: 404-778-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number78171
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number71871
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: