Healthcare Provider Details

I. General information

NPI: 1730354523
Provider Name (Legal Business Name): COMMUNITY PODIATRY & WOUND CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 SAINT JOHNS MEDICAL PARK DR
ST AUGUSTINE FL
32086-4233
US

IV. Provider business mailing address

1960 US HIGHWAY 1 SOUTH PMB 510
ST AUGUSTINE FL
32086-4233
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-3301
  • Fax: 904-823-3328
Mailing address:
  • Phone: 904-823-3301
  • Fax: 904-823-3328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2734
License Number StateFL

VIII. Authorized Official

Name: ROSANA RODRIGUEZ
Title or Position: DOCTOR
Credential: DPM
Phone: 904-823-3301