Healthcare Provider Details

I. General information

NPI: 1295745560
Provider Name (Legal Business Name): GULF COAST PODIATRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 HARRISON AVE UNIT 201
PANAMA CITY FL
32405-4447
US

IV. Provider business mailing address

2507 HARRISON AVE UNIT 201
PANAMA CITY FL
32405-4447
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-0325
  • Fax: 850-769-4476
Mailing address:
  • Phone: 850-769-0325
  • Fax: 850-769-4476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: SHAYNE JENSEN
Title or Position: PRESIDENT
Credential: DMD
Phone: 850-769-0325