Provider Demographics
NPI:1679548168
Name:BRODY, EVAN M (DPM)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:M
Last Name:BRODY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 STILESBORO RD NW STE 205
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7765
Mailing Address - Country:US
Mailing Address - Phone:678-310-0540
Mailing Address - Fax:678-310-0538
Practice Address - Street 1:5205 STILESBORO RD NW STE 205
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7765
Practice Address - Country:US
Practice Address - Phone:678-310-0540
Practice Address - Fax:678-310-0538
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000937213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581994261OtherFIRST HEALTH
GA2700264OtherUNITED HEALTHCARE
GA581994261OtherASSURANT HEALTH
GA1400101OtherGHI
GA457858901AMedicaid
GA10055122OtherAMERIGROUP - MEDICAID
GA581994261OtherHUMANA
GA3262431OtherAETNA
GA6241458OtherCIGNA
GA2701694OtherEVERCARE
GA332208Medicaid
GA581994261OtherHUMANA
GA581994261OtherFIRST HEALTH
GA332208Medicaid
GA6241458OtherCIGNA