Coastal Foot & Ankle Wellness Center LLC

Primary specialty

Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X

License

P02829 Issued in FL

Legal business name

COASTAL FOOT & ANKLE WELLNESS CENTER LLC

Practice address

1740 Tree Blvd Ste 112
St Augustine, FL 32084-5720

Phone

(904) 826-1900

Fax

(904) 826-1920

NPI assigned

Jan 19, 2010

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Richard W Johnson, DPMNPI 1477590248

Title

Owner

Phone

(904) 826-1900

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in FL2 enrollments

Enrollment records 2

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Richard W Johnson, DPM

  • Podiatrist
  • St Augustine, FL
  • NPI 1477590248

  FL, Podiatrist

  Medicare reassignment Care Compare group NPD Authorized official
• Jose M Concha, DPM

  • Podiatrist
  • St Augustine, FL
  • NPI 1992742142

  FL, Podiatrist

  Medicare reassignment Care Compare group NPD
• Roman Ivankiv

  • Foot Surgery Podiatrist
  • St Augustine, FL
  • NPI 1528517331

  FL, Foot Surgery

  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1263859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1609027200000",
    "number": "1972834760",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1740 TREE BLVD STE 112",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320845720",
            "telephone_number": "904-826-1900",
            "fax_number": "904-826-1920"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1740 TREE BLVD STE 112",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320845720",
            "telephone_number": "904-826-1900",
            "fax_number": "904-826-1920"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL FOOT & ANKLE WELLNESS CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-01-19",
        "last_updated": "2020-12-27",
        "certification_date": "2020-12-27",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "904-826-1900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "FL",
            "license": "P02829",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF FLORIDA",
            "identifier": "000NU",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in St Augustine, FL
• Foot & Ankle Surgery Podiatrist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.