=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417901604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAZIB N. KHAWAJA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2006
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 DIXIE ST SUITE 401
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30117-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-836-9326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 AMBULANCE DR 202
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30117-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-838-8710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 058888
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | 058888
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 25860
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------