Healthcare Provider Details

I. General information

NPI: 1114003274
Provider Name (Legal Business Name): ORLANDO FOOT AND ANKLE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 S INTERNATIONAL PKWY STE 1061
LAKE MARY FL
32746-1412
US

IV. Provider business mailing address

P O BOX 140233
ORLANDO FL
32814-0233
US

V. Phone/Fax

Practice location:
  • Phone: 407-323-1234
  • Fax: 407-322-8523
Mailing address:
  • Phone: 407-423-1234
  • Fax: 407-517-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: GREGORY RENTON
Title or Position: CEO
Credential:
Phone: 407-423-1234