Provider Demographics
NPI:1326040114
Name:DPM BRISSETT NRGA LLC
Entity Type:Organization
Organization Name:DPM BRISSETT NRGA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRISSETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:646-721-2072
Mailing Address - Street 1:5124 GROVE FIELD PT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2387
Mailing Address - Country:US
Mailing Address - Phone:646-721-2072
Mailing Address - Fax:866-678-9749
Practice Address - Street 1:5124 GROVE FIELD PT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2387
Practice Address - Country:US
Practice Address - Phone:646-721-2072
Practice Address - Fax:866-678-9749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000950213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA48SCIQWOtherMEDICARE
U51937Medicare UPIN
GAGRP7042Medicare ID - Type Unspecified