Provider Demographics
NPI:1194288373
Name:SHAHBAZIAN, KEVIN (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:SHAHBAZIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST # BA1404
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:813-598-5501
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST # BI5070
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108022085R0202X, 207R00000X
GA988882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine