Healthcare Provider Details

I. General information

NPI: 1598127151
Provider Name (Legal Business Name): FOOT ANKLE & WOUND CARE CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 DUNN AVE SUITE #3
JACKSONVILLE FL
32218-4720
US

IV. Provider business mailing address

2262 DUNN AVE SUITE #3
JACKSONVILLE FL
32218-4720
US

V. Phone/Fax

Practice location:
  • Phone: 904-666-5170
  • Fax:
Mailing address:
  • Phone: 904-666-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3624
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO3308
License Number StateFL

VIII. Authorized Official

Name: MS. DIANDRA K GORDON
Title or Position: OWNER/CEO
Credential: DPM
Phone: 904-666-5170