Provider Demographics
NPI:1831250240
Name:PAUL N GOTKIN & DAVID A GUBERNICK DPM PA
Entity type:Organization
Organization Name:PAUL N GOTKIN & DAVID A GUBERNICK DPM PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:N
Authorized Official - Last Name:GOTKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:772-286-9912
Mailing Address - Street 1:2291 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4530
Mailing Address - Country:US
Mailing Address - Phone:772-286-9912
Mailing Address - Fax:772-286-2405
Practice Address - Street 1:1090 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-3640
Practice Address - Country:US
Practice Address - Phone:772-461-2575
Practice Address - Fax:772-461-0419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029741100Medicaid
77424Medicare ID - Type Unspecified
FLU16651Medicare UPIN
FLU53122Medicare UPIN
FL029741100Medicaid