Provider Demographics
NPI:1295745560
Name:GULF COAST PODIATRY, PA
Entity type:Organization
Organization Name:GULF COAST PODIATRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-769-0325
Mailing Address - Street 1:2507 HARRISON AVE UNIT 201
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4447
Mailing Address - Country:US
Mailing Address - Phone:850-769-0325
Mailing Address - Fax:850-769-4476
Practice Address - Street 1:2507 HARRISON AVE UNIT 201
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4447
Practice Address - Country:US
Practice Address - Phone:850-769-0325
Practice Address - Fax:850-769-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45803OtherBLUECROSSBLUESHIELD
FLCK8386OtherRR MEDICARE
FLCK8386OtherRR MEDICARE
FLK1974Medicare UPIN
FL5417050001Medicare NSC