Provider Demographics
NPI:1144352386
Name:POLISNER, RICHARD I (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:I
Last Name:POLISNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 ROSCOE BLVD N
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2526
Mailing Address - Country:US
Mailing Address - Phone:904-273-9384
Mailing Address - Fax:
Practice Address - Street 1:4621 EMERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4920
Practice Address - Country:US
Practice Address - Phone:904-994-0990
Practice Address - Fax:904-212-1373
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1333213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
K7545Medicare ID - Type UnspecifiedMEDICARE ID#
T36190Medicare UPIN