Provider Demographics
NPI:1144280991
Name:BOBB, BRIAN SHAWN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SHAWN
Last Name:BOBB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3254 KENSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1651
Mailing Address - Country:US
Mailing Address - Phone:918-531-6121
Mailing Address - Fax:855-270-9668
Practice Address - Street 1:882 PONCE DE LEON AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4268
Practice Address - Country:US
Practice Address - Phone:770-809-3034
Practice Address - Fax:404-347-9445
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-09-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK23821207Q00000X
TXM7864207Q00000X
GA93772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8988OtherINDIVIDUAL MEDICARE NUMBER
GAG36231AOtherPALMETTO GBA MEDICARE ID
H65248Medicare UPIN