Healthcare Provider Details

I. General information

NPI: 1073000337
Provider Name (Legal Business Name): SHANE RAVI MAHABIR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2018
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY FL 2
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-294-3836
  • Fax:
Mailing address:
  • Phone: 404-892-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number102892
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: