Healthcare Provider Details

I. General information

NPI: 1033684816
Provider Name (Legal Business Name): ADAM DEAN PORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 PEACHTREE PKWY STE 100
NORCROSS GA
30092-2823
US

IV. Provider business mailing address

1975 HIGHWAY 54 W STE 205
PEACHTREE CITY GA
30269-4794
US

V. Phone/Fax

Practice location:
  • Phone: 770-368-6215
  • Fax: 770-368-6261
Mailing address:
  • Phone: 678-902-0457
  • Fax: 770-415-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001397
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: