Provider Demographics
NPI:1063414522
Name:SHAH, RAKESH RASIKLAL (MD)
Entity type:Individual
Prefix:DR
First Name:RAKESH
Middle Name:RASIKLAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 OAK FOREST CIR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5253
Mailing Address - Country:US
Mailing Address - Phone:404-697-5625
Mailing Address - Fax:888-669-9073
Practice Address - Street 1:4010 OAK FOREST CIRCLE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:404-697-5625
Practice Address - Fax:888-669-9073
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36761207P00000X
NMMD2016-0649207R00000X
GA056220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110234591OtherRAILROAD MEDICARE
1031935036Medicare NSC
TN110234591OtherRAILROAD MEDICARE