Provider Demographics
NPI:1053612101
Name:TAGHECHIAN, SHAYA (MD)
Entity type:Individual
Prefix:DR
First Name:SHAYA
Middle Name:
Last Name:TAGHECHIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:SUITE 430
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-429-9100
Practice Address - Fax:770-429-1391
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65188208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110961AMedicaid
FT2339439OtherDEA
GA003110961AMedicaid