Healthcare Provider Details

I. General information

NPI: 1487819173
Provider Name (Legal Business Name): ALIYA MATTHEWS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALIYA FAGAN

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 04/18/2020
Certification Date: 04/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 BENTLEY ESTATES DR
DACULA GA
30019-7786
US

IV. Provider business mailing address

1204 BENTLEY ESTATES DR
DACULA GA
30019-7786
US

V. Phone/Fax

Practice location:
  • Phone: 609-922-1866
  • Fax:
Mailing address:
  • Phone: 609-922-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSC006065
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001184
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006065
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number01490
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: