Healthcare Provider Details

I. General information

NPI: 1134267636
Provider Name (Legal Business Name): GWINNETT PODIATRY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30045-3389
US

IV. Provider business mailing address

545 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30045-3389
US

V. Phone/Fax

Practice location:
  • Phone: 770-963-6300
  • Fax: 770-682-0578
Mailing address:
  • Phone: 770-963-6300
  • Fax: 770-682-0578

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: MANAGING PARTNER
Credential: DPM
Phone: 770-232-9778