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General NPI Number Information
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NPI Number | 1457756470
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Entity Type | Organization
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Legal Business Name | DIABETIC FOOT AND ANKLE CLINIC OF GEORGIA, INC
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Dates
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Enumeration Date | 11/03/2014
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Last Update Date | 11/03/2014
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Provider Practice Location Address
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Address Line | 101 JOHN MADDOX DR NW SUITE A
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City | ROME
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State | GA
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Zip | 30165-1419
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Country | US
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Telephone | 706-232-6739
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Fax |
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Provider Business Mailing Address
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Address Line | 3364 MEDINA DR
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City | JONESBORO
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State | GA
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Zip | 30236-6873
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Country | US
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Telephone | 646-842-0447
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. AZUKA NWAEDOZIE
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Credential | DPM
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Telephone | 706-232-6739
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | POD001142
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License Number State | GA
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