MEDICARE: DESTIN PODIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	PO3084	FL

General Provider Information

NPI Number	:	1427389220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTIN PODIATRY LLC

Provider Business Mailing Address
First Line	:	2441 US HIGHWAY 98 W STE 102
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-5386
Country	:	US
Telephone Number	:	850-650-6492
Fax Number	:	850-650-2178

Provider Business Practice Location Address
First Line	:	2441 US HIGHWAY 98 W STE 102
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-5386
Country	:	US
Telephone Number	:	850-650-6492
Fax Number	:	850-650-2178

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS WHITFIELD ROBERTS
Credential	:	DPM
Telephone Number	:	850-650-6492

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	06/13/2024

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