Provider Demographics
NPI:1043203920
Name:MASSA, ERIC G (DPM)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:G
Last Name:MASSA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5337
Mailing Address - Country:US
Mailing Address - Phone:912-283-7596
Mailing Address - Fax:912-283-1618
Practice Address - Street 1:39 KENT RD
Practice Address - Street 2:SUITE 9
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1649
Practice Address - Country:US
Practice Address - Phone:229-382-3338
Practice Address - Fax:229-382-3247
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001073213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00389076OtherRAILROAD MEDICARE
52223803OtherBLUE SHIELD
GA244934736AMedicaid
GA48SCCWMMedicare PIN
GA244934736AMedicaid
5243400001Medicare NSC