Healthcare Provider Details

I. General information

NPI: 1033195979
Provider Name (Legal Business Name): RYAN J PEREIRA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 203
ST AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 203A
ST AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-0821
  • Fax: 904-461-0823
Mailing address:
  • Phone: 904-461-0821
  • Fax: 904-461-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3002
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: