Healthcare Provider Details

I. General information

NPI: 1215291133
Provider Name (Legal Business Name): VIVEK K SHENOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2174 N DRUID HILLS RD NE
ATLANTA GA
30329-3102
US

IV. Provider business mailing address

2174 N DRUID HILLS RD NE
ATLANTA GA
30329-3102
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 404-785-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAN 1992975-N-062
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2019-01253
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number101201
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: