Healthcare Provider Details

I. General information

NPI: 1285854448
Provider Name (Legal Business Name): GULFCOAST FOOT & ANKLE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11181 HEALTH PARK BOULEVARD SUITE #1180
NAPLES FL
34110-5738
US

IV. Provider business mailing address

P.O. BOX 110759
NAPLES FL
34108-0113
US

V. Phone/Fax

Practice location:
  • Phone: 239-566-8800
  • Fax: 239-566-8778
Mailing address:
  • Phone: 239-566-8800
  • Fax: 239-566-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO0002638
License Number StateFL

VIII. Authorized Official

Name: MR. MICKEY EDSON GORDON
Title or Position: OWNER/PRESIDENT
Credential: D.P.M.
Phone: 239-566-8800