Healthcare Provider Details

I. General information

NPI: 1932189115
Provider Name (Legal Business Name): VINCENT LOUIS TRAVISANO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2006
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7509 BIG BEND BLVD
SAINT LOUIS MO
63119-2103
US

IV. Provider business mailing address

7509 BIG BEND BLVD
SAINT LOUIS MO
63119-2103
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-3113
  • Fax: 314-968-7529
Mailing address:
  • Phone: 314-961-3113
  • Fax: 314-968-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000459
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: