Provider Demographics
NPI:1285001933
Name:LOGANVILLE FOOT AND ANKLE
Entity Type:Organization
Organization Name:LOGANVILLE FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRST
Authorized Official - Prefix:
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-639-4209
Mailing Address - Street 1:3529 HIGHWAY 81 S
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-0043
Mailing Address - Country:US
Mailing Address - Phone:678-639-4209
Mailing Address - Fax:678-639-4210
Practice Address - Street 1:3529 HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4336
Practice Address - Country:US
Practice Address - Phone:678-639-4209
Practice Address - Fax:678-639-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001006213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA829746724OMedicaid