=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821079138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FIROZ M PATKA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 PEACHTREE ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30434-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-625-7597
-----------------------------------------------------
Fax | 478-625-8364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3621 BURNING TREE CT.
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-868-0466
-----------------------------------------------------
Fax | 706-869-0098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 035499
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------