Provider Demographics
NPI:1285656181
Name:AUSTIN-HARRIS, CORLISS LA-SHUNUETTE (DPM, MS)
Entity Type:Individual
Prefix:DR
First Name:CORLISS
Middle Name:LA-SHUNUETTE
Last Name:AUSTIN-HARRIS
Suffix:
Gender:F
Credentials:DPM, MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:770 VILLAGE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3380
Mailing Address - Country:US
Mailing Address - Phone:404-298-8998
Mailing Address - Fax:404-298-7658
Practice Address - Street 1:770 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3380
Practice Address - Country:US
Practice Address - Phone:404-298-8998
Practice Address - Fax:404-298-7658
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPOD000689213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480023572OtherRAILROAD MEDICARE
GA000536357BMedicaid
GAU41116Medicare UPIN
GA000536357BMedicaid