Provider Demographics
NPI:1174506877
Name:MELBOURNE PODIATRY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:MELBOURNE PODIATRY ASSOCIATES, P.A.
Other - Org Name:MELBOURNE PODIATRY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOYLES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-723-3500
Mailing Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2946
Mailing Address - Country:US
Mailing Address - Phone:321-723-3500
Mailing Address - Fax:321-723-1945
Practice Address - Street 1:1515 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2946
Practice Address - Country:US
Practice Address - Phone:321-723-3500
Practice Address - Fax:321-723-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL72224OtherBCBS
FL041009800Medicaid
FL0528660001Medicare NSC
FL72224Medicare PIN