Provider Demographics
NPI:1053506162
Name:DIABETIC FOOT CARE SPECIALIST OF GEORGIA
Entity Type:Organization
Organization Name:DIABETIC FOOT CARE SPECIALIST OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:IOLA
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-759-6755
Mailing Address - Street 1:238 WALKER ST SW
Mailing Address - Street 2:UNIT #12
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30313-1266
Mailing Address - Country:US
Mailing Address - Phone:404-759-6755
Mailing Address - Fax:334-271-3768
Practice Address - Street 1:238 WALKER ST SW
Practice Address - Street 2:UNIT #12
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30313-1266
Practice Address - Country:US
Practice Address - Phone:404-759-6755
Practice Address - Fax:334-271-3768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000681213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA48SCCXCMedicare PIN