=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720811508
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE SANDS PODIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 SOUTH FERDON BLVD
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536
-----------------------------------------------------
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 | OWNER/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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------