=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932818267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN A. CRIST DPM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2022
-----------------------------------------------------
Last Update Date | 11/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 2ND AVE N STE 204
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-5701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-272-1185
-----------------------------------------------------
Fax | 718-732-2063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 111324
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34108-0123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-272-1185
-----------------------------------------------------
Fax | 239-732-2063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JOHN A CRIST
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 239-272-1185
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------