Healthcare Provider Details

I. General information

NPI: 1679177661
Provider Name (Legal Business Name): TIMOTHY C. RUNYON, D.P.M. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12681 NEW BRITTANY BLVD # 1E
FORT MYERS FL
33907-3631
US

IV. Provider business mailing address

12681 NEW BRITTANY BLVD # 1E
FORT MYERS FL
33907-3631
US

V. Phone/Fax

Practice location:
  • Phone: 239-689-3843
  • Fax: 239-689-3852
Mailing address:
  • Phone: 239-689-3843
  • Fax: 239-689-3852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

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