Healthcare Provider Details

I. General information

NPI: 1417692260
Provider Name (Legal Business Name): KARISSA JANISSE BADILLO STORER DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8350 RIVERWALK PARK BLVD STE 1
FORT MYERS FL
33919-8759
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3044
  • Fax: 239-468-7962
Mailing address:
  • Phone: 239-343-3044
  • Fax: 239-468-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.004184
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36.004184
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4761
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: