Provider Demographics
NPI:1710514609
Name:HUFFAKER, THOMAS BERRY
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BERRY
Last Name:HUFFAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1121
Mailing Address - Country:US
Mailing Address - Phone:801-662-8557
Mailing Address - Fax:
Practice Address - Street 1:875 JOHNSON FY RD NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1418
Practice Address - Country:US
Practice Address - Phone:404-835-4191
Practice Address - Fax:404-835-4190
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA98882207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology