Provider Demographics
NPI:1508155037
Name:EASY WALK FOOT CLINIC LLC
Entity Type:Organization
Organization Name:EASY WALK FOOT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AZUKA
Authorized Official - Middle Name:IFEYINWA
Authorized Official - Last Name:NWAEDOZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-489-6589
Mailing Address - Street 1:3364 MEDINA DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-6873
Mailing Address - Country:US
Mailing Address - Phone:646-489-6589
Mailing Address - Fax:678-489-6522
Practice Address - Street 1:101 BECKETT LN
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7155
Practice Address - Country:US
Practice Address - Phone:678-489-6589
Practice Address - Fax:678-489-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001142213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6503900002Medicare NSC