Provider Demographics
NPI:1023557204
Name:FLORIDA FOOT & ANKLE GROUP PA
Entity Type:Organization
Organization Name:FLORIDA FOOT & ANKLE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:407-323-2566
Mailing Address - Street 1:522 S HUNT CLUB BLVD # 344
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4960
Mailing Address - Country:US
Mailing Address - Phone:407-297-9800
Mailing Address - Fax:407-296-6272
Practice Address - Street 1:178 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5352
Practice Address - Country:US
Practice Address - Phone:407-671-8010
Practice Address - Fax:407-671-4155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013593800Medicaid
FLIU644ZMedicare UPIN
FL24366Medicare PIN