Healthcare Provider Details

I. General information

NPI: 1194721308
Provider Name (Legal Business Name): SHAHIN ETEBAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 10/31/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1538 13TH AVE STE B300
COLUMBUS GA
31901-2563
US

IV. Provider business mailing address

1538 13TH AVE STE B300
COLUMBUS GA
31901-2563
US

V. Phone/Fax

Practice location:
  • Phone: 706-321-9300
  • Fax: 706-243-1284
Mailing address:
  • Phone: 706-321-9300
  • Fax: 706-243-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89571
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberG72753
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number89571
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: