Basic Information
| Provider Information | |||||||||
| NPI: | 1518348168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORLANDO FOOT & ANKLE CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORLANDO FOOT & ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140233 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328140233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074231234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 E HOWRY AVE | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074231234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2015 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | RENTON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4074231234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 029602300 | 05 | FL | MEDICAID |