Healthcare Provider Details

I. General information

NPI: 1649408501
Provider Name (Legal Business Name): GLORIED MARIE EBSWORTH DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5304 S FLORIDA AVE STE 406
LAKELAND FL
33813-4914
US

IV. Provider business mailing address

5304 S FLORIDA AVE STE 406
LAKELAND FL
33813-4914
US

V. Phone/Fax

Practice location:
  • Phone: 863-738-6601
  • Fax: 863-937-3002
Mailing address:
  • Phone: 863-738-6601
  • Fax: 863-937-3002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 3550
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO 3550
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: