Healthcare Provider Details

I. General information

NPI: 1821079138
Provider Name (Legal Business Name): FIROZ M PATKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 PEACHTREE ST
LOUISVILLE GA
30434-1449
US

IV. Provider business mailing address

3621 BURNING TREE CT.
MARTINEZ GA
30907
US

V. Phone/Fax

Practice location:
  • Phone: 478-625-7597
  • Fax: 478-625-8364
Mailing address:
  • Phone: 706-868-0466
  • Fax: 706-869-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number035499
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: