Healthcare Provider Details

I. General information

NPI: 1497738413
Provider Name (Legal Business Name): TRACY SMITH MAYBERRY DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY ALETTA SMITH DPM

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 02/08/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1683 WASHINGTON RD
EAST POINT GA
30344-4265
US

IV. Provider business mailing address

1683 WASHINGTON ROAD
EAST POINT GA
30344-4265
US

V. Phone/Fax

Practice location:
  • Phone: 404-766-6400
  • Fax: 404-766-6450
Mailing address:
  • Phone: 404-766-6400
  • Fax: 404-766-6450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000763
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD000763
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberPOD000763
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPOD000763
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000763
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD000763
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: