Healthcare Provider Details

I. General information

NPI: 1568003275
Provider Name (Legal Business Name): DEREK CHARLES GAFFEY MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13025 BIRMINGHAM HWY
MILTON GA
30004-7306
US

IV. Provider business mailing address

1203 SPRING CREEK LN
SANDY SPRINGS GA
30350-3814
US

V. Phone/Fax

Practice location:
  • Phone: 470-254-7000
  • Fax:
Mailing address:
  • Phone: 814-594-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT003069
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: