Provider Demographics
NPI:1760590004
Name:ORLANDO FOOT AND ANKLE CLINIC, INC
Entity Type:Organization
Organization Name:ORLANDO FOOT AND ANKLE CLINIC, INC
Other - Org Name:ORLANDO FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-423-1234
Mailing Address - Street 1:P O BOX 140233
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-0233
Mailing Address - Country:US
Mailing Address - Phone:407-423-1234
Mailing Address - Fax:407-517-1040
Practice Address - Street 1:1525 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4140
Practice Address - Country:US
Practice Address - Phone:407-957-3244
Practice Address - Fax:407-957-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDB3528OtherR/R MEDICARE
FL029602300Medicaid
FLDB3528OtherR/R MEDICARE
FL029602300Medicaid