Provider Demographics
NPI:1215008768
Name:GAINESVILLE PODIATRY CLINIC, INC
Entity Type:Organization
Organization Name:GAINESVILLE PODIATRY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-536-9908
Mailing Address - Street 1:1975 BEVERLY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2034
Mailing Address - Country:US
Mailing Address - Phone:770-536-9908
Mailing Address - Fax:770-532-7102
Practice Address - Street 1:1975 BEVERLY ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3726
Practice Address - Country:US
Practice Address - Phone:770-536-9908
Practice Address - Fax:770-532-7102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055002335AMedicaid
GAGRP2044Medicare PIN
GA055002335AMedicaid