Provider Demographics
NPI:1457756470
Name:DIABETIC FOOT AND ANKLE CLINIC OF GEORGIA, INC
Entity Type:Organization
Organization Name:DIABETIC FOOT AND ANKLE CLINIC OF GEORGIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AZUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAEDOZIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:706-232-6739
Mailing Address - Street 1:3364 MEDINA DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-6873
Mailing Address - Country:US
Mailing Address - Phone:646-842-0447
Mailing Address - Fax:
Practice Address - Street 1:101 JOHN MADDOX DR NW
Practice Address - Street 2:SUITE A
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1419
Practice Address - Country:US
Practice Address - Phone:706-232-6739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty