Healthcare Provider Details

I. General information

NPI: 1013085513
Provider Name (Legal Business Name): GWINNETT CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/25/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 LAWRENCEVILLE HWY
TUCKER GA
30084-2952
US

IV. Provider business mailing address

10600 MEDLOCK BRIDGE RD
DULUTH GA
30097-8404
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-1429
  • Fax: 770-270-5854
Mailing address:
  • Phone: 770-995-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEEP SHAH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD, MSC
Phone: 770-995-3300