Healthcare Provider Details

I. General information

NPI: 1215008768
Provider Name (Legal Business Name): GAINESVILLE PODIATRY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 BEVERLY ROAD SUITE B
GAINESVILLE GA
30501-3726
US

IV. Provider business mailing address

1975 BEVERLY RD SUITE B
GAINESVILLE GA
30501-2034
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-9908
  • Fax: 770-532-7102
Mailing address:
  • Phone: 770-536-9908
  • Fax: 770-532-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateGA

VIII. Authorized Official

Name: WESLEY LEWIS DANIEL
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 770-536-9908