Provider Demographics
NPI:1477946820
Name:ADVANCED WOUND CARE OF NORTH FLORIDA, LLC
Entity Type:Organization
Organization Name:ADVANCED WOUND CARE OF NORTH FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DEMETRIOS
Authorized Official - Last Name:LAGOUTARIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-380-1492
Mailing Address - Street 1:108 PRINCE PHILLIP DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1746
Mailing Address - Country:US
Mailing Address - Phone:813-380-1492
Mailing Address - Fax:
Practice Address - Street 1:13500 SUTTON PARK DR S
Practice Address - Street 2:SUITE 403
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5251
Practice Address - Country:US
Practice Address - Phone:904-493-3390
Practice Address - Fax:904-493-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3240213EP1101X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV10291Medicare UPIN
FLK4593AMedicare PIN