Healthcare Provider Details

I. General information

NPI: 1144352386
Provider Name (Legal Business Name): RICHARD I POLISNER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4621 EMERSON ST
JACKSONVILLE FL
32207-4920
US

IV. Provider business mailing address

335 ROSCOE BLVD N
PONTE VEDRA BEACH FL
32082-2526
US

V. Phone/Fax

Practice location:
  • Phone: 904-994-0990
  • Fax: 904-212-1373
Mailing address:
  • Phone: 904-273-9384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO1333
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: