Healthcare Provider Details

I. General information

NPI: 1245427525
Provider Name (Legal Business Name): SOUTHEASTERN PODIATRY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 WALDO PALMER LN STE 1A
TALLAHASSEE FL
32308-6049
US

IV. Provider business mailing address

1580 WALDO PALMER LN STE 1A
TALLAHASSEE FL
32308-6049
US

V. Phone/Fax

Practice location:
  • Phone: 850-942-0096
  • Fax:
Mailing address:
  • Phone: 850-942-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2918
License Number StateFL

VIII. Authorized Official

Name: PAUL REYNOLDS
Title or Position: PRESIDENT
Credential: DPM
Phone: 850-942-0096