Provider Demographics
NPI:1629573217
Name:TIDEWATER FOOT & ANKLE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:TIDEWATER FOOT & ANKLE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-925-9431
Mailing Address - Street 1:13019 W LINEBAUGH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4507
Mailing Address - Country:US
Mailing Address - Phone:813-925-9431
Mailing Address - Fax:
Practice Address - Street 1:13019 W LINEBAUGH AVE STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626
Practice Address - Country:US
Practice Address - Phone:813-925-9431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3663213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7720870001OtherDMERC