Provider Demographics
NPI:1306841374
Name:HAVRILLA, GEORGE S (DPM)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:S
Last Name:HAVRILLA
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 1:544 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2117
Mailing Address - Country:US
Mailing Address - Phone:706-595-8787
Mailing Address - Fax:706-595-8757
Practice Address - Street 1:544 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2117
Practice Address - Country:US
Practice Address - Phone:706-595-8787
Practice Address - Fax:706-595-8757
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2013-02-14
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
GA000848213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5040540001OtherDME PROVIDER #
GA322007OtherWELLCARE OF GEORGIA
GA10581911OtherCIGNA
GA5467067OtherAETNA
GA618552906AMedicaid
GA10041458OtherAMERIGROUP
GA52773057-003OtherBLUE CROSS BLUE SHIELD
GA10041458OtherAMERIGROUP
GA52773057-003OtherBLUE CROSS BLUE SHIELD
GA48SCCNBMedicare PIN
GA5467067OtherAETNA