Provider Demographics
NPI:1285854448
Name:GULFCOAST FOOT & ANKLE CENTER, INC.
Entity Type:Organization
Organization Name:GULFCOAST FOOT & ANKLE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:EDSON
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-566-8800
Mailing Address - Street 1:P.O. BOX 110759
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-0113
Mailing Address - Country:US
Mailing Address - Phone:239-566-8800
Mailing Address - Fax:239-566-8778
Practice Address - Street 1:11181 HEALTH PARK BOULEVARD
Practice Address - Street 2:SUITE #1180
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-5738
Practice Address - Country:US
Practice Address - Phone:239-566-8800
Practice Address - Fax:239-566-8778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002638213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093729592OtherINDIVIDUAL NPI
FL1285854448OtherNPI
1689644882OtherINDIVIDUAL NPI
FL1285854448OtherNPI
FLK6801Medicare UPIN
5082890001Medicare NSC