Healthcare Provider Details

I. General information

NPI: 1477946820
Provider Name (Legal Business Name): ADVANCED WOUND CARE OF NORTH FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 03/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 SUTTON PARK DR S SUITE 403
JACKSONVILLE FL
32224-5251
US

IV. Provider business mailing address

108 PRINCE PHILLIP DR
ST AUGUSTINE FL
32092-1746
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-3390
  • Fax: 904-493-3395
Mailing address:
  • Phone: 813-380-1492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO3240
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3240
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO3240
License Number StateFL

VIII. Authorized Official

Name: JOHN DEMETRIOS LAGOUTARIS
Title or Position: OWNER
Credential: DPM
Phone: 813-380-1492