Healthcare Provider Details

I. General information

NPI: 1669452611
Provider Name (Legal Business Name): AFFILIATED FOOT AND ANKLE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 PEACHTREE INDUSTRIAL BLVD STE 110
DULUTH GA
30097-8607
US

IV. Provider business mailing address

3071 PEACHTREE INDUSTRIAL BLVD STE 110
DULUTH GA
30097-8607
US

V. Phone/Fax

Practice location:
  • Phone: 770-232-9778
  • Fax: 770-232-9776
Mailing address:
  • Phone: 770-232-9778
  • Fax: 770-232-9776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00742
License Number StateGA

VIII. Authorized Official

Name: DR. RICHARD P MISTRETTA
Title or Position: CFO/TREASURER
Credential: DPM
Phone: 770-232-9778