Provider Demographics
NPI:1104806157
Name:MISTRETTA, RICHARD (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MISTRETTA
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 1:3071 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE # 110
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-7917
Mailing Address - Country:US
Mailing Address - Phone:770-232-9778
Mailing Address - Fax:770-232-9776
Practice Address - Street 1:3071 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE # 110
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-7917
Practice Address - Country:US
Practice Address - Phone:770-232-9778
Practice Address - Fax:770-232-9776
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00742213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00630825EMedicaid
GA1160300002Medicare NSC
GA48SCBRKMedicare PIN
GAU40819Medicare UPIN