Provider Demographics
NPI:1891178406
Name:NORTHRUP, JOHN RANDALL (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:NORTHRUP
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 1:1690 US HIGHWAY 1 S STE C
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6024
Mailing Address - Country:US
Mailing Address - Phone:904-436-8001
Mailing Address - Fax:904-376-7761
Practice Address - Street 1:1690 US HIGHWAY 1 S STE C
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6024
Practice Address - Country:US
Practice Address - Phone:904-436-8001
Practice Address - Fax:904-377-6776
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3952213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101521600Medicaid