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

Last updated

Dec 27, 2020By the provider in NPPES

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

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, and the practitioner matching its NPPES authorized official.

• Richard W Johnson, DPM

  • Podiatrist
  • St Augustine, FL
  • NPI 1477590248
  Medicare reassignment Care Compare group NPD Authorized official
• Jose M Concha, DPM

  • Podiatrist
  • St Augustine, FL
  • NPI 1992742142
  Medicare reassignment Care Compare group NPD
• Roman Ivankiv

  • Foot Surgery Podiatrist
  • St Augustine, FL
  • NPI 1528517331
  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": [],
    "endpoints": [],
    "other_names": []
}

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• Foot & Ankle Surgery Podiatrist in St Augustine, FL
• Providers in St Augustine, FL by specialty
• 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.