Healthcare Provider Details

I. General information

NPI: 1861816860
Provider Name (Legal Business Name): VANESSA MIRASOL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VETERANS AVE
BILOXI MS
39531
US

IV. Provider business mailing address

356 GINGER DR BOX 7414
DIBERVILLE MS
39540-9081
US

V. Phone/Fax

Practice location:
  • Phone: 228-523-5000
  • Fax:
Mailing address:
  • Phone: 228-760-1235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberP205
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: