Healthcare Provider Details

I. General information

NPI: 1629573217
Provider Name (Legal Business Name): TIDEWATER FOOT & ANKLE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3663
License Number StateFL

VIII. Authorized Official

Name: DR. MEGAN JOHNSON
Title or Position: OWNER/ PHYSICIAN
Credential: DPM
Phone: 813-925-9431