Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | GA053964 | GA |
N | 207QA0401X | Family Doctor - Addiction Medicine | 053964 | GA |
NPI | 1326149139 |
---|---|
Provider Name | Dr. Bereaval Shamarol Webb |
First Address | Atlanta, GA 30318-6029 |
Second Address | Atlanta, GA 30346-3401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 17/12/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I40294 | (02) | GA |