Healthcare Provider Details

I. General information

NPI: 1194725002
Provider Name (Legal Business Name): FOOT & ANKLE GROUP OF SOUTHWEST FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 CONGDON RD APT 200
FORT MYERS FL
33908-5004
US

IV. Provider business mailing address

7117 CONGDON RD APT 200
FORT MYERS FL
33908-5004
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-5400
  • Fax: 239-936-9572
Mailing address:
  • Phone: 239-936-5400
  • Fax: 239-936-9572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-1326
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-2020
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-1693
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-3722
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO-3613
License Number StateFL

VIII. Authorized Official

Name: JEROLD S. GOLDSTEIN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 239-936-5400