Healthcare Provider Details

I. General information

NPI: 1912189218
Provider Name (Legal Business Name): FOOT & ANKLE CLINIC OF OAKWOOD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 MUNDY MILL PL SUITE A
OAKWOOD GA
30566-2573
US

IV. Provider business mailing address

4220 MUNDY MILL PL SUITE A
OAKWOOD GA
30566-2573
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-7008
  • Fax: 770-536-1550
Mailing address:
  • Phone: 770-536-7008
  • Fax: 770-536-1550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS ANOTHONY BROSKY II
Title or Position: PRESIDENT
Credential: DPM
Phone: 770-536-7008