Provider Demographics
NPI:1700375458
Name:SUNSHINE STATE PODIATRY LLC
Entity Type:Organization
Organization Name:SUNSHINE STATE PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-404-7793
Mailing Address - Street 1:8353 SW 124TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5847
Mailing Address - Country:US
Mailing Address - Phone:239-703-9301
Mailing Address - Fax:
Practice Address - Street 1:24830 BURNT PINE DR STE 3
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1974
Practice Address - Country:US
Practice Address - Phone:239-703-9301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3984213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3990OtherDEPARTMENT OF HEALTH
FLPO3984OtherDEPARTMENT OF HEALTH FLORIDA