Provider Demographics
NPI:1073574083
Name:GREGORY, JIMMY LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:LEE
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2140 CALVERTON LANE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-1210
Mailing Address - Country:US
Mailing Address - Phone:404-284-7744
Mailing Address - Fax:404-284-8006
Practice Address - Street 1:3546 COVINGTON HWY
Practice Address - Street 2:SUITE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1823
Practice Address - Country:US
Practice Address - Phone:404-284-7744
Practice Address - Fax:404-284-8006
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000598213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10038991OtherAMERIGROUP
GA000430504GOtherPEACH STATE
GA000430504GMedicaid
GA309352OtherWELLCARE
GA48SCCMSMedicare PIN
GA000430504GOtherPEACH STATE