MEDICARE: SHIVA MAHINRAD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME92524	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922093095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIVA MAHINRAD M.D.

Provider Business Mailing Address
First Line	:	PO BOX 746638
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-6638
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	2310 VILLAGE SQUARE PKWY STE 206
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-6409
Country	:	US
Telephone Number	:	904-264-4405
Fax Number	:	904-391-5380

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	05/28/2024

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