Healthcare Provider Details

I. General information

NPI: 1679276596
Provider Name (Legal Business Name): SIDRA SHAKIL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 DULUTH HWY STE 401
LAWRENCEVILLE GA
30046-4303
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-1000
  • Fax:
Mailing address:
  • Phone: 678-312-1000
  • Fax: 678-312-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number113322
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number113322
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: