Provider Demographics
NPI:1912999004
Name:BRISSETT, ROBERT P (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:BRISSETT
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 1:5124 GROVE FIELD PT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2387
Mailing Address - Country:US
Mailing Address - Phone:678-994-8674
Mailing Address - Fax:866-678-9749
Practice Address - Street 1:5124 GROVE FIELD PT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2387
Practice Address - Country:US
Practice Address - Phone:678-994-8674
Practice Address - Fax:866-678-9749
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000950213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309363507AMedicaid
U51937Medicare UPIN
GA1912999004Medicare PIN