Provider Demographics
NPI:1669452611
Name:AFFILIATED FOOT AND ANKLE, PC
Entity Type:Organization
Organization Name:AFFILIATED FOOT AND ANKLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-232-9778
Mailing Address - Street 1:3071 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8607
Mailing Address - Country:US
Mailing Address - Phone:770-232-9778
Mailing Address - Fax:770-232-9776
Practice Address - Street 1:3071 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:STE 110
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8607
Practice Address - Country:US
Practice Address - Phone:770-232-9778
Practice Address - Fax:770-232-9776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00742213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00630825EMedicaid
GA00630825EMedicaid
GA1160300003Medicare NSC
GAGRP6404Medicare PIN