Healthcare Provider Details

I. General information

NPI: 1023557204
Provider Name (Legal Business Name): FLORIDA FOOT & ANKLE GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 WILSHIRE BLVD
CASSELBERRY FL
32707-5352
US

IV. Provider business mailing address

522 S HUNT CLUB BLVD # 344
APOPKA FL
32703-4960
US

V. Phone/Fax

Practice location:
  • Phone: 407-671-8010
  • Fax: 407-671-4155
Mailing address:
  • Phone: 407-297-9800
  • Fax: 407-296-6272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER E ROTH III
Title or Position: TREASURER
Credential: D.P.M.
Phone: 407-323-2566