Provider Demographics
NPI:1104832484
Name:MCCOY, KATANGA (DPM)
Entity Type:Individual
Prefix:DR
First Name:KATANGA
Middle Name:
Last Name:MCCOY
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 1:105 WEXFORD CIR
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-4734
Mailing Address - Country:US
Mailing Address - Phone:478-328-6466
Mailing Address - Fax:478-328-1338
Practice Address - Street 1:940 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4059
Practice Address - Country:US
Practice Address - Phone:478-328-6466
Practice Address - Fax:478-328-1338
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD0001008213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA48SCCQSMedicare ID - Type Unspecified
V02133Medicare UPIN