Provider Demographics
NPI:1700228897
Name:DESTIN PODIATRY, LLC
Entity Type:Organization
Organization Name:DESTIN PODIATRY, LLC
Other - Org Name:COASTAL FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WHITFIELD
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-650-6492
Mailing Address - Street 1:2441 US HIGHWAY 98 W STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-5386
Mailing Address - Country:US
Mailing Address - Phone:850-650-6492
Mailing Address - Fax:850-650-2178
Practice Address - Street 1:12216 PANAMA CITY BEACH PKWY STE C
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2728
Practice Address - Country:US
Practice Address - Phone:850-650-6492
Practice Address - Fax:850-650-2178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTIN PODIATRY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-18
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3084213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
65817ZMedicare PIN