Provider Demographics
NPI:1063885929
Name:FOOT AND ANKLE SPECIALIST OF GEORGIA, LLC
Entity type:Organization
Organization Name:FOOT AND ANKLE SPECIALIST OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-933-4291
Mailing Address - Street 1:3400 CHAPEL HILL RD
Mailing Address - Street 2:SUITE 321
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1739
Mailing Address - Country:US
Mailing Address - Phone:678-741-5346
Mailing Address - Fax:678-999-3030
Practice Address - Street 1:3400 CHAPEL HILL RD
Practice Address - Street 2:SUITE 321
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:678-741-5346
Practice Address - Fax:678-999-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001225213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003138997CMedicaid
GA003138997CMedicaid