1073574083 NPI number — DR. JIMMY LEE GREGORY DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073574083 NPI number — DR. JIMMY LEE GREGORY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGORY
Provider First Name:
JIMMY
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073574083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2140 CALVERTON LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30331-1210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-284-7744
Provider Business Mailing Address Fax Number:
404-284-8006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 WINN WAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-1709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-284-7744
Provider Business Practice Location Address Fax Number:
404-284-8006
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  POD00598 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: POD000598 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10038991 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000430504G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000430504G . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 309352 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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