Provider Demographics
NPI:1699237461
Name:GEORGIAN, STEVEN BLAKELY
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:BLAKELY
Last Name:GEORGIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-673-4625
Mailing Address - Fax:601-673-4627
Practice Address - Street 1:872 WINTER ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5797
Practice Address - Country:US
Practice Address - Phone:601-673-4625
Practice Address - Fax:601-673-4627
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS80244213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program