Healthcare Provider Details

I. General information

NPI: 1588083331
Provider Name (Legal Business Name): MICHAEL GEVONTMAKHER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

125 TERRAMONT CT
ROSWELL GA
30076-2527
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-8912
  • Fax:
Mailing address:
  • Phone: 786-628-9186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011183
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: