MEDICARE: FOOT FIRST PODIATRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	PO 2195	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CZ576A	OTHER	FL	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053658963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT FIRST PODIATRY

Provider Business Mailing Address
First Line	:	PO BOX 1199
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32435-1199
Country	:	US
Telephone Number	:	407-443-9784
Fax Number	:	850-547-8090

Provider Business Practice Location Address
First Line	:	2600 HOSPITAL DR
Second Line	:
City	:	BONIFAY
State	:	FL
Zip	:	32425-4264
Country	:	US
Telephone Number	:	850-547-8117
Fax Number	:	850-547-8090

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KELVIN DEVANE GIPSON
Credential	:	DPM
Telephone Number	:	407-443-9784

Provider Enumeration Date	:	01/11/2013
Last Update Date	:	01/11/2013

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Directions to “FOOT FIRST PODIATRY ” Practice Location

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