Healthcare Provider Details

I. General information

NPI: 1700857406
Provider Name (Legal Business Name): RISA L VINARUB DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N COURTENAY PKWY
MERRITT ISLAND FL
32953-5500
US

IV. Provider business mailing address

1205 N COURTENAY PKWY
MERRITT ISLAND FL
32953-5500
US

V. Phone/Fax

Practice location:
  • Phone: 321-452-5133
  • Fax: 321-449-8713
Mailing address:
  • Phone: 321-452-5133
  • Fax: 321-449-8713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2414
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: