Provider Demographics
NPI:1144329160
Name:RIESCO, DOUGLAS (MSPT)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:RIESCO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12936 SW 133RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6951
Mailing Address - Country:US
Mailing Address - Phone:305-323-5833
Mailing Address - Fax:305-387-9332
Practice Address - Street 1:12936 SW 133RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6951
Practice Address - Country:US
Practice Address - Phone:305-323-5833
Practice Address - Fax:305-387-9332
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y021MZOtherMEDICARE
FL889975400Medicaid
Y021MZOtherMEDICARE
FL889975400Medicaid