Basic Information
Provider Information | |||||||||
NPI: | 1588772826 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORLANDO FOOT AND ANKLE CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ORLANDO FOOT & ANKLE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 140233 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328140233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4074231234 | ||||||||
FaxNumber: | 4075171040 | ||||||||
Practice Location | |||||||||
Address1: | 2111 GLENWOOD DR | ||||||||
Address2: | STE 104 | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 32792 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076471550 | ||||||||
FaxNumber: | 4076471561 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2006 | ||||||||
LastUpdateDate: | 01/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RENTON | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4074231234 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 029602300 | 05 | FL |   | MEDICAID | DB3528 | 01 | FL | R/R MEDICARE | OTHER |