Provider Demographics
NPI:1194721308
Name:ETEBAR, SHAHIN (MD)
Entity type:Individual
Prefix:
First Name:SHAHIN
Middle Name:
Last Name:ETEBAR
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 1:1538 13TH AVE STE B300
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2563
Mailing Address - Country:US
Mailing Address - Phone:706-321-9300
Mailing Address - Fax:706-243-1284
Practice Address - Street 1:1538 13TH AVE STE B300
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2563
Practice Address - Country:US
Practice Address - Phone:706-321-9300
Practice Address - Fax:706-243-1284
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA89571207Q00000X, 207T00000X
CAG72753207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G7275301Medicare ID - Type Unspecified
F49115Medicare UPIN