Basic Information
Provider Information
NPI: 1083883151
EntityType: 2
ReplacementNPI:  
OrganizationName: FOOT AND ANKLE CENTER OF MIDDLE GEORGIA, LLC
LastName:  
FirstName:  
MiddleName:  
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Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: PO BOX 6007
Address2:  
City: WARNER ROBINS
State: GA
PostalCode: 310956007
CountryCode: US
TelephoneNumber: 4789290036
FaxNumber: 4789291744
Practice Location
Address1: 1040 MORNINGSIDE DR
Address2:  
City: PERRY
State: GA
PostalCode: 310692904
CountryCode: US
TelephoneNumber: 4789884676
FaxNumber: 4789877907
Other Information
ProviderEnumerationDate: 02/22/2008
LastUpdateDate: 07/24/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: JOKHAI
AuthorizedOfficialFirstName: SARVEPALLI
AuthorizedOfficialMiddleName: D
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4789884676
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DPM
NPICertificationDate: 07/24/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213ES0103X000829GAY193400000X SINGLE SPECIALTY GROUPPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery

No ID Information.


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