Provider Demographics
NPI:1598127151
Name:FOOT ANKLE & WOUND CARE CENTER CORP
Entity Type:Organization
Organization Name:FOOT ANKLE & WOUND CARE CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-666-5170
Mailing Address - Street 1:2262 DUNN AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4720
Mailing Address - Country:US
Mailing Address - Phone:904-666-5170
Mailing Address - Fax:
Practice Address - Street 1:2262 DUNN AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4720
Practice Address - Country:US
Practice Address - Phone:904-666-5170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3624213ES0103X
FLPO3308213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010198600Medicaid