Healthcare Provider Details

I. General information

NPI: 1215164942
Provider Name (Legal Business Name): PURVI SHAAN SHAH DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2009
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S ENOTA DR NE STE 1
GAINESVILLE GA
30501-2433
US

IV. Provider business mailing address

590 S ENOTA DR NE
GAINESVILLE GA
30501-2433
US

V. Phone/Fax

Practice location:
  • Phone: 470-252-5756
  • Fax: 470-252-5756
Mailing address:
  • Phone: 770-418-0456
  • Fax: 770-418-1603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001208
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: