Healthcare Provider Details

I. General information

NPI: 1942006275
Provider Name (Legal Business Name): FTG ORTHO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 NE 203RD ST STE 100
AVENTURA FL
33180-1945
US

IV. Provider business mailing address

2627 NE 203RD ST STE 100
AVENTURA FL
33180-1945
US

V. Phone/Fax

Practice location:
  • Phone: 305-937-1999
  • Fax:
Mailing address:
  • Phone: 305-937-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DOMINIC J LEWIS
Title or Position: MGR
Credential: MD
Phone: 305-937-1999