Basic Information
| Provider Information | |||||||||
| NPI: | 1265570691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKALLA | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123033552 | ||||||||
| FaxNumber: | 9123033506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914100 | ||||||||
| FaxNumber: | 9126914289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 694 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000591093B | 05 | GA | MEDICAID |