Provider Demographics
NPI:1851362644
Name:PHELPS, JAYSON B (DPM)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:B
Last Name:PHELPS
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 1:135 LEE BYRD RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2310
Mailing Address - Country:US
Mailing Address - Phone:678-639-4209
Mailing Address - Fax:678-639-4210
Practice Address - Street 1:135 LEE BYRD RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2310
Practice Address - Country:US
Practice Address - Phone:678-639-4209
Practice Address - Fax:678-639-4210
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001006213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581994261OtherUNITED HEALTHCARE
GA829746724OMedicaid
GA10042144Medicaid
GA7595720OtherAETNA
GA322061Medicaid
GA2701740OtherEVERCARE
GA829746724AMedicaid
GA829746724BMedicaid
GA82974624AMedicaid
GA48SCCSTMedicare ID - Type Unspecified
GA829746724OMedicaid
GA82974624AMedicaid