Healthcare Provider Details

I. General information

NPI: 1508183732
Provider Name (Legal Business Name): FLORIDA FOOT & ANKLE GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 09/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 WILLISTON PARK PT SUITE 1009
LAKE MARY FL
32746-2114
US

IV. Provider business mailing address

522 S HUNT CLUB BLVD STE 344
APOPKA FL
32703-4960
US

V. Phone/Fax

Practice location:
  • Phone: 407-323-2566
  • Fax: 407-324-3577
Mailing address:
  • Phone: 407-323-2566
  • Fax: 407-324-3577

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: DR. WALTER E ROTH III
Title or Position: TREASURER
Credential: DPM
Phone: 407-323-2566