Provider Demographics
NPI:1255584744
Name:DEKALB FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:DEKALB FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:CORKRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:404-292-5676
Mailing Address - Street 1:5462 MEMORIAL DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3239
Mailing Address - Country:US
Mailing Address - Phone:404-292-5676
Mailing Address - Fax:404-299-8657
Practice Address - Street 1:5462 MEMORIAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3239
Practice Address - Country:US
Practice Address - Phone:404-292-5676
Practice Address - Fax:404-299-8657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030034207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty