Provider Demographics
NPI:1053658963
Name:FOOT FIRST PODIATRY
Entity Type:Organization
Organization Name:FOOT FIRST PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:DEVANE
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:407-443-9784
Mailing Address - Street 1:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-1199
Mailing Address - Country:US
Mailing Address - Phone:407-443-9784
Mailing Address - Fax:850-547-8090
Practice Address - Street 1:2600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-4264
Practice Address - Country:US
Practice Address - Phone:850-547-8117
Practice Address - Fax:850-547-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2195213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002040200Medicaid
FLCZ576AOtherMEDICARE PART B