Provider Demographics
NPI:1881876902
Name:FIRST COAST PODIATRY, P A
Entity type:Organization
Organization Name:FIRST COAST PODIATRY, P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAYNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-354-1192
Mailing Address - Street 1:3115 SPRING GLEN RD STE 507
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5907
Mailing Address - Country:US
Mailing Address - Phone:904-354-1192
Mailing Address - Fax:904-354-1193
Practice Address - Street 1:3115 SPRING GLEN RD STE 507
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5907
Practice Address - Country:US
Practice Address - Phone:904-354-1192
Practice Address - Fax:904-354-1193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2487213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340105700Medicaid
FL340105700Medicaid
FL65404ZMedicare PIN
FLU62077Medicare UPIN
FL6371250001Medicare NSC