Healthcare Provider Details

I. General information

NPI: 1033837992
Provider Name (Legal Business Name): TIDEWATER FOOT & ANKLE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4168 WOODLANDS PKWY STE B
PALM HARBOR FL
34685-3496
US

IV. Provider business mailing address

13019 W LINEBAUGH AVE STE 101
TAMPA FL
33626-4507
US

V. Phone/Fax

Practice location:
  • Phone: 813-925-9431
  • Fax:
Mailing address:
  • Phone: 813-925-9431
  • Fax: 813-925-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MEGAN BROOK JOHNSON
Title or Position: OWNER
Credential:
Phone: 813-925-9431