Provider Demographics
NPI:1134267636
Name:GWINNETT PODIATRY ASSOCIATES LLC
Entity type:Organization
Organization Name:GWINNETT PODIATRY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
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 1:545 OLD NORCROSS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3389
Mailing Address - Country:US
Mailing Address - Phone:770-963-6300
Mailing Address - Fax:770-682-0578
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3389
Practice Address - Country:US
Practice Address - Phone:770-963-6300
Practice Address - Fax:770-682-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00742213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty