Provider Demographics
NPI:1114487311
Name:ABC FEET INC
Entity Type:Organization
Organization Name:ABC FEET INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DIANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-534-7061
Mailing Address - Street 1:1629 REDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5028
Mailing Address - Country:US
Mailing Address - Phone:904-534-7061
Mailing Address - Fax:904-224-2002
Practice Address - Street 1:1126 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-8850
Practice Address - Country:US
Practice Address - Phone:904-765-5554
Practice Address - Fax:904-765-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty