Healthcare Provider Details

I. General information

NPI: 1942290705
Provider Name (Legal Business Name): MICHAEL K BEDNARZ DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N MEDICAL PKWY BLDG 100, SUITE 102
WOODSTOCK GA
30189-7062
US

IV. Provider business mailing address

1555 DOCTORS DR STE. 106
LAGRANGE GA
30240-4132
US

V. Phone/Fax

Practice location:
  • Phone: 770-926-4641
  • Fax: 770-926-1692
Mailing address:
  • Phone: 706-845-9370
  • Fax: 706-845-9371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001030
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: