Healthcare Provider Details

I. General information

NPI: 1891744090
Provider Name (Legal Business Name): SHAHINA MIRZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY PO BOX 1648
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-294-3835
  • Fax: 404-508-7795
Mailing address:
  • Phone: 404-294-3835
  • Fax: 404-508-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number027297
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: