Provider Demographics
NPI:1013120963
Name:FIRST COAST FOOT & ANKLE CLINIC INC
Entity Type:Organization
Organization Name:FIRST COAST FOOT & ANKLE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VIMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-739-9129
Mailing Address - Street 1:8075 GATE PKWY W
Mailing Address - Street 2:SUITE 301
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3684
Mailing Address - Country:US
Mailing Address - Phone:904-739-9129
Mailing Address - Fax:904-739-9127
Practice Address - Street 1:8075 GATE PKWY W
Practice Address - Street 2:SUITE 301
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-3684
Practice Address - Country:US
Practice Address - Phone:904-739-9129
Practice Address - Fax:904-739-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3091213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6330940002OtherDME PIN