Provider Demographics
NPI:1518943059
Name:PITTS, JON DARRYL (DPM)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DARRYL
Last Name:PITTS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5491 ROSWELL RD
Mailing Address - Street 2:STE B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-252-6662
Mailing Address - Fax:404-252-2727
Practice Address - Street 1:5491 ROSWELL RD
Practice Address - Street 2:STE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-6662
Practice Address - Fax:404-252-2727
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000877213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000838131Medicaid
GAGRP3733Medicare ID - Type Unspecified
GA000838131Medicaid
GA1301890001Medicare NSC