=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174977425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL N GOTKIN, DPM & DAVID A GUBERNICK, DPM PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2016
-----------------------------------------------------
Last Update Date | 02/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N PARROTT AVE
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34972-2918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-484-8001
-----------------------------------------------------
Fax | 772-286-2405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2291 SE FEDERAL HWY
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-286-9912
-----------------------------------------------------
Fax | 772-286-2405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PODIATRIST
-----------------------------------------------------
Name | DR. DAVID A GUBERNICK
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 772-286-9912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------