Provider Demographics
NPI:1578869046
Name:POWELL, DONALD RUBERTINO (DPM)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:RUBERTINO
Last Name:POWELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:KIRK
Other - Last Name:MOSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1975 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4794
Mailing Address - Country:US
Mailing Address - Phone:678-561-9000
Mailing Address - Fax:770-487-1232
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:STE 1615
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2212
Practice Address - Country:US
Practice Address - Phone:678-702-0620
Practice Address - Fax:678-702-0621
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD00135213ES0103X
FLPO3482213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131663CMedicaid
GA202I487348OtherMEDICARE PTAN
GA003131663BMedicaid
GA003131663AMedicaid