Healthcare Provider Details

I. General information

NPI: 1417264722
Provider Name (Legal Business Name): FIRST COAST PODIATRIC SURGERY AND WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 UNIVERSITY BLVD S SUITE 504
JACKSONVILLE FL
32216-7411
US

IV. Provider business mailing address

PO BOX 1653
ORANGE PARK FL
32067-1653
US

V. Phone/Fax

Practice location:
  • Phone: 904-637-0037
  • Fax:
Mailing address:
  • Phone: 904-637-0037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 3294
License Number StateFL

VIII. Authorized Official

Name: DR. JORG ALEXANDER BOBER
Title or Position: OWNER/PODIATRIST
Credential: DPM
Phone: 904-422-1566