Healthcare Provider Details

I. General information

NPI: 1770015547
Provider Name (Legal Business Name): JONATHAN FREEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 N POINT PKWY SUITE 207
ALPHARETTA GA
30005-4248
US

IV. Provider business mailing address

818 WINDY TRAIL
LAFAYETTE GA
30728
US

V. Phone/Fax

Practice location:
  • Phone: 770-559-8725
  • Fax: 770-559-8276
Mailing address:
  • Phone: 770-559-8725
  • Fax: 770-559-8276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number04-168
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: