Healthcare Provider Details

I. General information

NPI: 1700540549
Provider Name (Legal Business Name): TIMOTHY C. RUNYON, DPM, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 DEL PRADO BLVD S STE 303
CAPE CORAL FL
33990-3601
US

IV. Provider business mailing address

1401 16TH ST N
ST PETERSBURG FL
33704-4123
US

V. Phone/Fax

Practice location:
  • Phone: 239-689-3843
  • Fax: 239-689-3852
Mailing address:
  • Phone: 727-894-0794
  • Fax: 727-895-1215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: KYLE J KINMON
Title or Position: PRESIDENT/ OWNER
Credential: DPM
Phone: 561-995-0229