Provider Demographics
NPI:1164497665
Name:MERRITT, STEPHANIE C (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:MERRITT
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 VILLAGE GREEN CIR SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3476
Mailing Address - Country:US
Mailing Address - Phone:770-384-0284
Mailing Address - Fax:770-432-7638
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR
Practice Address - Street 2:SUITE 220
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7668
Practice Address - Country:US
Practice Address - Phone:678-208-0700
Practice Address - Fax:678-208-0705
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000856213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU81578Medicare UPIN
GA48SCCSQMedicare ID - Type Unspecified