Healthcare Provider Details

I. General information

NPI: 1225575855
Provider Name (Legal Business Name): NORTHEAST GEORGIA PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 470-252-5756
  • Fax:
Mailing address:
  • Phone: 470-252-5756
  • Fax:

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: PURVI SHAAN SHAH
Title or Position: PODIATRIST
Credential: DPM
Phone: 470-439-0324