Provider Demographics
NPI:1194156158
Name:GULFCOAST FOOT AND ANKLE CENTER
Entity type:Organization
Organization Name:GULFCOAST FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:EDSON
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPN
Authorized Official - Phone:239-566-8800
Mailing Address - Street 1:9955 TAMIAMI TRL N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1914
Mailing Address - Country:US
Mailing Address - Phone:239-566-8800
Mailing Address - Fax:239-566-8778
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:SUITE 2150
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-949-3399
Practice Address - Fax:239-949-6553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULFCOAST FOOT AND ANKLE CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002638213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT97329Medicare UPIN
FL65543ZMedicare PIN