Provider Demographics
NPI:1568491421
Name:HEALTH PARK FOOT & ANKLE ASSOCIATES INC
Entity Type:Organization
Organization Name:HEALTH PARK FOOT & ANKLE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:W
Authorized Official - Last Name:MALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-825-0046
Mailing Address - Street 1:1975 OLD MOULTRIE RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5164
Mailing Address - Country:US
Mailing Address - Phone:904-825-0046
Mailing Address - Fax:904-826-1586
Practice Address - Street 1:1975 OLD MOULTRIE RD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5164
Practice Address - Country:US
Practice Address - Phone:904-825-0046
Practice Address - Fax:904-826-1586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340409900Medicaid
FLK0788BMedicare PIN
FLK0788AMedicare PIN
FL340409900Medicaid
FLK0788Medicare PIN