Individual
JOB TIMENY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
11100 SUMMER RIDGE LN, FORT MYERS, FL 33908-4064
(239) 344-2348
(239) 479-5194
Mailing address
PO BOX 919771, ORLANDO, FL 32891-0001
(239) 278-3600
(239) 479-5202
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
LL9559
MD
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
PO3490
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004775300
—
FL
Enumeration date
07/16/2011
Last updated
07/06/2022
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