Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 343 | GA |
Y | 222Z00000X | Podiatrist | 343 | GA |
NPI | 1033287214 |
---|---|
Provider Name | Jerome Fredrick Poeppelman |
First Address | Stone Mountain, GA 30086 |
Second Address | Stone Mountain, GA 30086 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T98075 | (02) |