MEDICARE: FANCY FEET PODIATRY PA

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	261QP1100X	Podiatric Clinic/Center

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	:	1962908525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FANCY FEET PODIATRY PA

Provider Business Mailing Address
First Line	:	3905 W MULLEN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4426
Country	:	US
Telephone Number	:	917-930-0497
Fax Number	:

Provider Business Practice Location Address
First Line	:	2123 W DR MARTIN LUTHER KING JR BLVD STE 103
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6545
Country	:	US
Telephone Number	:	813-999-1716
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CATHERINE STANIMIROV
Credential	:	DPM
Telephone Number	:	917-930-0497

Provider Enumeration Date	:	04/03/2018
Last Update Date	:	11/10/2020

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Directions to “FANCY FEET PODIATRY PA ” Practice Location

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