Provider Demographics
NPI:1740841071
Name:KETTINGER, SAMUEL JAMES (DPM)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JAMES
Last Name:KETTINGER
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 1:450 W CENTRAL PKWY STE 1000
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2433
Mailing Address - Country:US
Mailing Address - Phone:321-397-2699
Mailing Address - Fax:407-926-0500
Practice Address - Street 1:450 W CENTRAL PKWY STE 1000
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2433
Practice Address - Country:US
Practice Address - Phone:321-397-2699
Practice Address - Fax:407-926-0500
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLPO4304213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program