Healthcare Provider Details

I. General information

NPI: 1801568431
Provider Name (Legal Business Name): ST. JOHNS PODIATRY & WOUND CARE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NATURE WALK PWKY STE. 105
SAINT AUGUSTINE FL
32092
US

IV. Provider business mailing address

230 MORNING MIST LN
SAINT JOHNS FL
32259-8511
US

V. Phone/Fax

Practice location:
  • Phone: 315-382-5910
  • Fax:
Mailing address:
  • Phone: 315-382-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. DANIEL A BLACK
Title or Position: OWNER OF TIN/PRACTICE
Credential: DPM
Phone: 315-382-5910