Provider Demographics
NPI:1326612813
Name:RESIDOVIC, MIRSADA
Entity Type:Individual
Prefix:
First Name:MIRSADA
Middle Name:
Last Name:RESIDOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8685 BAYMEADOWS RD E APT 331
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1908
Mailing Address - Country:US
Mailing Address - Phone:904-338-2072
Mailing Address - Fax:
Practice Address - Street 1:340 16TH AVE N STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4819
Practice Address - Country:US
Practice Address - Phone:904-249-8893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist