Healthcare Provider Details

I. General information

NPI: 1134408164
Provider Name (Legal Business Name): FAMILY PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NW 43RD ST SUITE 2
GAINESVILLE FL
32607-6126
US

IV. Provider business mailing address

500 NW 43D ST. 2
GAINESVILLE FL
32607-6126
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-5112
  • Fax: 352-376-0320
Mailing address:
  • Phone: 352-376-5112
  • Fax: 352-376-0320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO 2501
License Number StateFL

VIII. Authorized Official

Name: DR. SCOTT KOPPEL
Title or Position: PRESIDENT
Credential: DPM
Phone: 352-376-5112