1093027815 NPI number — FLORIDA PODIATRY PA

Table of content: (NPI 1093027815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093027815 NPI number — FLORIDA PODIATRY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA PODIATRY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093027815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
335 CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-3181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-672-9797
Provider Business Mailing Address Fax Number:
386-615-0460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 CLYDE MORRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-3181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-672-9797
Provider Business Practice Location Address Fax Number:
386-615-0460
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
386-672-9797

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com