=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659765865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE SANDS PODIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2015
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 S FERDON BLVD
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-4238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-1607
-----------------------------------------------------
Fax | 888-302-6552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 981 US HWY 98 STE 3410
-----------------------------------------------------
City | DESTIN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-1607
-----------------------------------------------------
Fax | 888-302-6552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | SEAN CHARLES HODSON
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 850-622-1607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO3469
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------