Provider Demographics
NPI:1801568431
Name:ST. JOHNS PODIATRY & WOUND CARE SPECIALISTS LLC
Entity type:Organization
Organization Name:ST. JOHNS PODIATRY & WOUND CARE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF TIN/PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:315-382-5910
Mailing Address - Street 1:230 MORNING MIST LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-8511
Mailing Address - Country:US
Mailing Address - Phone:315-382-5910
Mailing Address - Fax:
Practice Address - Street 1:113 NATURE WALK PWKY
Practice Address - Street 2:STE. 105
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092
Practice Address - Country:US
Practice Address - Phone:315-382-5910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty