Healthcare Provider Details

I. General information

NPI: 1699359174
Provider Name (Legal Business Name): OPTIMUM PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5077 DALLAS HWY STE 311
POWDER SPRINGS GA
30127-4510
US

IV. Provider business mailing address

5077 DALLAS HWY STE 311
POWDER SPRINGS GA
30127-4510
US

V. Phone/Fax

Practice location:
  • Phone: 770-727-0614
  • Fax: 770-799-8453
Mailing address:
  • Phone: 770-727-0614
  • Fax: 770-799-8453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALVIN J COWANS II
Title or Position: OWNER
Credential: DPM
Phone: 770-727-0614