Healthcare Provider Details

I. General information

NPI: 1871586115
Provider Name (Legal Business Name): ROBERT C. WIRT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 S ENOTA DR NE
GAINESVILLE GA
30501-2545
US

IV. Provider business mailing address

601 S ENOTA DR NE SUITE Q
GAINESVILLE GA
30501-2400
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-7777
  • Fax: 770-219-7778
Mailing address:
  • Phone: 770-219-8420
  • Fax: 770-219-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number026686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: