Healthcare Provider Details

I. General information

NPI: 1912999004
Provider Name (Legal Business Name): ROBERT P BRISSETT DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5124 GROVE FIELD PT
LITHONIA GA
30038-2387
US

IV. Provider business mailing address

5124 GROVE FIELD PT
LITHONIA GA
30038-2387
US

V. Phone/Fax

Practice location:
  • Phone: 678-994-8674
  • Fax: 866-678-9749
Mailing address:
  • Phone: 678-994-8674
  • Fax: 866-678-9749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD000950
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: