Provider Demographics
NPI:1104235613
Name:DIVINE PODIATRY
Entity type:Organization
Organization Name:DIVINE PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-922-1866
Mailing Address - Street 1:1204 BENTLEY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7786
Mailing Address - Country:US
Mailing Address - Phone:609-922-1866
Mailing Address - Fax:
Practice Address - Street 1:1204 BENTLEY ESTATES DR
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7786
Practice Address - Country:US
Practice Address - Phone:609-922-1866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD00148213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty