Basic Information
Provider Information | |||||||||
NPI: | 1467444570 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MITCHELL-SMITH | ||||||||
FirstName: | LA'GENIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 CIRCLE 75 PKWY.SE | ||||||||
Address2: | SUITE 900 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303393084 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6784262171 | ||||||||
FaxNumber: | 4044461957 | ||||||||
Practice Location | |||||||||
Address1: | 550 PEACHTREE STREET | ||||||||
Address2: | SUITE 1960 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303082225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4045891330 | ||||||||
FaxNumber: | 4045891387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 02/03/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD001024 | GA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.