=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174675409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A CRIST DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 02/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1443 LAKELAND HILLS BLVD
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-686-6200
-----------------------------------------------------
Fax | 813-752-0093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 CREEKSIDE PKWY BOX 111324
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34108-1153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-272-1185
-----------------------------------------------------
Fax | 718-732-2063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO 1768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | PO 1768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------