Provider Demographics
NPI:1457482622
Name:WILLIAMSBURG FOOT & ANKLE SPECIALISTS P.C.
Entity Type:Organization
Organization Name:WILLIAMSBURG FOOT & ANKLE SPECIALISTS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-220-3311
Mailing Address - Street 1:PO BOX 5635
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5210
Mailing Address - Country:US
Mailing Address - Phone:757-220-3311
Mailing Address - Fax:757-220-9070
Practice Address - Street 1:453 MCLAWS CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-5645
Practice Address - Country:US
Practice Address - Phone:757-220-3311
Practice Address - Fax:757-220-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000917213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA115887OtherANTHEM
VA5672190001Medicare NSC
VAC08953Medicare PIN