Healthcare Provider Details

I. General information

NPI: 1275857542
Provider Name (Legal Business Name): SHIVAN H AMIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 10/31/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 CURRAN ST NW STE 101
ATLANTA GA
30318-5430
US

IV. Provider business mailing address

1120 CURRAN ST NW STE 101
ATLANTA GA
30318-5430
US

V. Phone/Fax

Practice location:
  • Phone: 404-228-9961
  • Fax: 404-973-2901
Mailing address:
  • Phone: 267-456-4313
  • Fax: 404-501-7212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA108630
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number67525
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: