Healthcare Provider Details

I. General information

NPI: 1457482622
Provider Name (Legal Business Name): WILLIAMSBURG FOOT & ANKLE SPECIALISTS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 MCLAWS CIR SUITE 1
WILLIAMSBURG VA
23185-5645
US

IV. Provider business mailing address

PO BOX 5635
WILLIAMSBURG VA
23188-5210
US

V. Phone/Fax

Practice location:
  • Phone: 757-220-3311
  • Fax: 757-220-9070
Mailing address:
  • Phone: 757-220-3311
  • Fax: 757-220-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number0103000917
License Number StateVA

VIII. Authorized Official

Name: DR. MARK ALLYN GARDNER
Title or Position: PRESIDENT
Credential: DPM
Phone: 757-220-3311