Provider Demographics
NPI:1649316092
Name:MUHANNA, SHAJIH L (MD)
Entity type:Individual
Prefix:
First Name:SHAJIH
Middle Name:L
Last Name:MUHANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:203 MEDICAL WAY
Mailing Address - Street 2:STE A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274
Mailing Address - Country:US
Mailing Address - Phone:770-991-1319
Mailing Address - Fax:770-991-1320
Practice Address - Street 1:203 MEDICAL WAY
Practice Address - Street 2:STE A
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:770-991-1319
Practice Address - Fax:770-991-1320
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0150272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000073389BMedicaid
GA000073389BMedicaid