Healthcare Provider Details

I. General information

NPI: 1093361602
Provider Name (Legal Business Name): DANIEL ZAVADIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2019
Last Update Date: 06/11/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N PARK PL STE 101
STOCKBRIDGE GA
30281-7237
US

IV. Provider business mailing address

135 N PARK PL STE 101
STOCKBRIDGE GA
30281-7237
US

V. Phone/Fax

Practice location:
  • Phone: 770-892-0300
  • Fax:
Mailing address:
  • Phone: 757-274-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: