MEDICARE: JONATHAN BARAK FASS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	046089	GA

General Provider Information

NPI Number	:	1104821917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN BARAK FASS MD

Provider Business Mailing Address
First Line	:	1180 RESURGENCE DR STE 100
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-7211
Country	:	US
Telephone Number	:	706-543-5858
Fax Number	:	706-543-2050

Provider Business Practice Location Address
First Line	:	1000 COWLES CLINIC WAY STE 100
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-5285
Country	:	US
Telephone Number	:	706-543-5858
Fax Number	:	706-543-2050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	01/25/2024

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