Provider Demographics
NPI:1578773750
Name:JIMMY L. GREGORY DPM, INC
Entity Type:Organization
Organization Name:JIMMY L. GREGORY DPM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-284-7744
Mailing Address - Street 1:2140 CALVERTON LANE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2235
Mailing Address - Country:US
Mailing Address - Phone:404-202-8916
Mailing Address - Fax:404-284-8006
Practice Address - Street 1:3546 COVINGTON HWY
Practice Address - Street 2:SUITE C
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1823
Practice Address - Country:US
Practice Address - Phone:404-284-7744
Practice Address - Fax:404-284-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000598213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6110OtherMEDICARE PART B
GADC7572OtherMEDICARE RAILROAD
GAT78996Medicare UPIN
6258020001Medicare NSC