Provider Demographics
NPI:1679550628
Name:MIDDLETON, BRIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:MIDDLETON
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30164-2400
Mailing Address - Country:US
Mailing Address - Phone:706-802-1800
Mailing Address - Fax:706-802-0781
Practice Address - Street 1:211 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1537
Practice Address - Country:US
Practice Address - Phone:706-802-1800
Practice Address - Fax:706-802-0781
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000618213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000427567AMedicaid
GAU00992Medicare UPIN
48SCBPPMedicare ID - Type Unspecified
GA4692630001Medicare NSC