Healthcare Provider Details

I. General information

NPI: 1629110473
Provider Name (Legal Business Name): TONY GAYLE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 HEADLAND DR JENCARE NEIGHBORHOOD MEDICAL CENTER EAST POINT, LLC
EAST POINT GA
30344
US

IV. Provider business mailing address

624 EL PRADO CT
STONE MOUNTAIN GA
30083-3822
US

V. Phone/Fax

Practice location:
  • Phone: 404-965-5691
  • Fax: 404-965-5707
Mailing address:
  • Phone: 678-938-0159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD001076
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD001076
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPOD001076
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001076
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD001076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: