Provider Demographics
NPI:1508387796
Name:GEORGIA BLUE FOOT AND ANKLE,LLC
Entity Type:Organization
Organization Name:GEORGIA BLUE FOOT AND ANKLE,LLC
Other - Org Name:WATSON AND COWANS FOOT AND ANKLE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/ PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MATRECE
Authorized Official - Last Name:GREEN- WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:407-844-4499
Mailing Address - Street 1:310 COLLEGIATE DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4333
Mailing Address - Country:US
Mailing Address - Phone:407-844-4499
Mailing Address - Fax:
Practice Address - Street 1:3387 HIGHWAY 5 STE H
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6900
Practice Address - Country:US
Practice Address - Phone:800-891-4930
Practice Address - Fax:770-741-0775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001319213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty