Healthcare Provider Details

I. General information

NPI: 1174793046
Provider Name (Legal Business Name): ANKLE & FOOT CENTER OF TAMPA BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S MOON AVE SUITE #101
BRANDON FL
33511-5703
US

IV. Provider business mailing address

2835 W DE LEON ST SUITE #101
TAMPA FL
33609-4130
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-0123
  • Fax: 813-661-1423
Mailing address:
  • Phone: 813-254-4747
  • Fax: 813-254-8262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E CREIGHTON
Title or Position: MEMBER
Credential: DPM
Phone: 813-254-4747