Provider Demographics
NPI:1093809097
Name:CENTRAL FLORIDA FOOT AND ANKLE
Entity Type:Organization
Organization Name:CENTRAL FLORIDA FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WELLENS-BRUSCHAYT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, PHD
Authorized Official - Phone:863-299-4551
Mailing Address - Street 1:PO BOX 7472
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33883-7472
Mailing Address - Country:US
Mailing Address - Phone:863-299-4551
Mailing Address - Fax:863-299-2310
Practice Address - Street 1:101 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4630
Practice Address - Country:US
Practice Address - Phone:863-299-4551
Practice Address - Fax:863-299-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2760213ES0103X
FLPO2804213ES0103X
FLPO3070213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2460Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
FL4756410003Medicare NSC