Healthcare Provider Details

I. General information

NPI: 1083802490
Provider Name (Legal Business Name): NUSRAT UL SHAFI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GATEWAY CORPORATE BLVD STE 350
COLUMBIA SC
29203-9785
US

IV. Provider business mailing address

PO BOX 935722
ATLANTA GA
31193-5722
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-2277
  • Fax: 803-788-6508
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32383
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: