Healthcare Provider Details

I. General information

NPI: 1053774596
Provider Name (Legal Business Name): SOLE PODIATRY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 GOLDEN GATE PKWY STE 4
NAPLES FL
34116-7529
US

IV. Provider business mailing address

5475 GOLDEN GATE PKWY STE 4
NAPLES FL
34116-7529
US

V. Phone/Fax

Practice location:
  • Phone: 239-353-1555
  • Fax: 239-353-7001
Mailing address:
  • Phone: 239-353-1555
  • Fax: 239-353-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP03769
License Number StateFL

VIII. Authorized Official

Name: DR. SEAN M. KIBRIA
Title or Position: PHYSICIAN
Credential: D.P.M.
Phone: 239-353-1555