Healthcare Provider Details

I. General information

NPI: 1548571060
Provider Name (Legal Business Name): DIANDRA KAREEN GORDON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 01/11/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 REDSTONE CT
ST AUGUSTINE FL
32092-5028
US

IV. Provider business mailing address

1629 REDSTONE CT
ST AUGUSTINE FL
32092-5028
US

V. Phone/Fax

Practice location:
  • Phone: 904-534-7061
  • Fax: 904-659-8331
Mailing address:
  • Phone: 904-534-7061
  • Fax: 904-659-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: