Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 036722 | GA |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 036722 | GA |
NPI | 1114929189 |
---|---|
Provider Name | Xavier Ampuero Duralde |
First Address | Atlanta, GA 30309-1476 |
Second Address | Atlanta, GA 30309-1414 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2005 |
Last Update Date | 24/02/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00544585A | (05) | GA |
F56200 | (02) |