Provider Demographics
NPI:1235559188
Name:ORLANDO FOOT AND ANKLE CLINIC, INC
Entity Type:Organization
Organization Name:ORLANDO FOOT AND ANKLE CLINIC, INC
Other - Org Name:ORLANDO FOOT AND ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-423-1234
Mailing Address - Street 1:PO BOX 140233
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-0233
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:10417 MOSS PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832
Practice Address - Country:US
Practice Address - Phone:407-737-2751
Practice Address - Fax:407-781-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-18
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029602300Medicaid
FL029602300Medicaid