Provider Demographics
NPI:1649408501
Name:EBSWORTH, GLORIED MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLORIED
Middle Name:MARIE
Last Name:EBSWORTH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5304 S FLORIDA AVE STE 400F
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4914
Mailing Address - Country:US
Mailing Address - Phone:863-738-6601
Mailing Address - Fax:863-937-3002
Practice Address - Street 1:5304 S FLORIDA AVE STE 400F
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4914
Practice Address - Country:US
Practice Address - Phone:863-738-6601
Practice Address - Fax:863-937-3002
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3550213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006315500Medicaid