Healthcare Provider Details

I. General information

NPI: 1477909786
Provider Name (Legal Business Name): MICHAEL THOMAS ROSSIDIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 W WASHINGTON AVE STE 160
LAS VEGAS NV
89128-4356
US

IV. Provider business mailing address

7455 W WASHINGTON AVE STE 160
LAS VEGAS NV
89128-4356
US

V. Phone/Fax

Practice location:
  • Phone: 702-878-0393
  • Fax: 702-258-3777
Mailing address:
  • Phone: 702-878-0393
  • Fax: 702-258-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2087
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006730
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: