Provider Demographics
NPI:1962583799
Name:SHAH, KAUSHIK SUKHENDRA (MD)
Entity type:Individual
Prefix:MR
First Name:KAUSHIK
Middle Name:SUKHENDRA
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1000 HAWTHORNE AVE
Mailing Address - Street 2:SUITE M
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-548-8010
Mailing Address - Fax:706-548-8068
Practice Address - Street 1:1000 HAWTHORNE AVE
Practice Address - Street 2:SUITE M
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-548-8010
Practice Address - Fax:706-548-8068
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023225207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000237839BMedicaid
GAAS9566778OtherDEA