Healthcare Provider Details

I. General information

NPI: 1689293375
Provider Name (Legal Business Name): DANIELLE LEE MUSTICO DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CORTEZ RD W
BRADENTON FL
34207-1335
US

IV. Provider business mailing address

1800 CORTEZ RD W
BRADENTON FL
34207-1335
US

V. Phone/Fax

Practice location:
  • Phone: 941-758-8818
  • Fax:
Mailing address:
  • Phone: 941-541-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO4488
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO4488
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPDT.0000589
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO4488
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4488
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: