Provider Demographics
NPI:1790960508
Name:PENSACOLA PODIATRY, P.A.
Entity Type:Organization
Organization Name:PENSACOLA PODIATRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:H
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-476-2805
Mailing Address - Street 1:6160 N DAVIS HWY
Mailing Address - Street 2:STE 1
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-6967
Mailing Address - Country:US
Mailing Address - Phone:850-476-2805
Mailing Address - Fax:850-476-3010
Practice Address - Street 1:6160 N DAVIS HWY
Practice Address - Street 2:STE 1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6967
Practice Address - Country:US
Practice Address - Phone:850-476-2805
Practice Address - Fax:850-476-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040994400Medicaid
FLK1811Medicare PIN
FL040994400Medicaid