Provider Demographics
NPI:1811538390
Name:MODERN PODIATRY, LLC
Entity Type:Organization
Organization Name:MODERN PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIBIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:WANZU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:470-781-5585
Mailing Address - Street 1:1270 HIGHWAY 314
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5449
Mailing Address - Country:US
Mailing Address - Phone:813-300-4449
Mailing Address - Fax:
Practice Address - Street 1:990 BEAR CREEK BLVD STE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:470-781-5585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-04
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003233587AMedicaid