MEDICARE: ABC FEET INC

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

General Provider Information

NPI Number	:	1114487311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABC FEET INC

Provider Business Mailing Address
First Line	:	1629 REDSTONE CT
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-5028
Country	:	US
Telephone Number	:	904-534-7061
Fax Number	:	904-224-2002

Provider Business Practice Location Address
First Line	:	1126 UNIVERSITY BLVD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-8850
Country	:	US
Telephone Number	:	904-765-5554
Fax Number	:	904-765-9302

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	DIANDRA K GORDON
Credential	:	DPM
Telephone Number	:	904-534-7061

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	09/29/2020

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Directions to “ABC FEET INC ” Practice Location

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