MEDICARE: OPTIMUM PODIATRY LLC

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	213EP1101X	Primary Podiatric Medicine Podiatrist

General Provider Information

NPI Number	:	1699359174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM PODIATRY LLC

Provider Business Mailing Address
First Line	:	5077 DALLAS HWY STE 311
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4510
Country	:	US
Telephone Number	:	770-727-0614
Fax Number	:	770-799-8453

Provider Business Practice Location Address
First Line	:	5077 DALLAS HWY STE 311
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4510
Country	:	US
Telephone Number	:	770-727-0614
Fax Number	:	770-799-8453

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALVIN J COWANS II
Credential	:	DPM
Telephone Number	:	770-727-0614

Provider Enumeration Date	:	05/10/2021
Last Update Date	:	04/25/2022

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