Basic Information
| Provider Information | |||||||||
| NPI: | 1578869046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | RUBERTINO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOSLEY | ||||||||
| OtherFirstName: | DONALD | ||||||||
| OtherMiddleName: | KIRK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1975 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785619000 | ||||||||
| FaxNumber: | 7704871232 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | STE 1615 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787020620 | ||||||||
| FaxNumber: | 6787020621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | POD00135 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | PO3482 | FL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003131663C | 05 | GA | MEDICAID | 202I487348 | 01 | GA | MEDICARE PTAN | OTHER | 003131663B | 05 | GA | MEDICAID | 003131663A | 05 | GA | MEDICAID |