Provider Demographics
NPI:1881657740
Name:RUNYON, TIMOTHY C (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:C
Last Name:RUNYON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-4123
Mailing Address - Country:US
Mailing Address - Phone:727-894-0794
Mailing Address - Fax:727-895-1215
Practice Address - Street 1:1401 16TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4123
Practice Address - Country:US
Practice Address - Phone:727-894-0794
Practice Address - Fax:727-895-1215
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFP1101332B00000X
FLPO1101213ES0000X, 213EP1101X, 213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0854680001OtherDMERC
FL041079900Medicaid
FL0854680001OtherDMERC
FLT55440Medicare UPIN