Provider Demographics
NPI:1477909786
Name:ROSSIDIS, MICHAEL THOMAS (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:ROSSIDIS
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 1:7455 W WASHINGTON AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4356
Mailing Address - Country:US
Mailing Address - Phone:702-878-0393
Mailing Address - Fax:702-258-3777
Practice Address - Street 1:7455 W WASHINGTON AVE STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4356
Practice Address - Country:US
Practice Address - Phone:702-878-0393
Practice Address - Fax:702-258-3777
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2087213ES0103X
PASC006730213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program