Provider Demographics
NPI:1720030950
Name:RIEGERT-JOHNSON, VANESSA Z (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:Z
Last Name:RIEGERT-JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 PRUDENTIAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8188
Mailing Address - Country:US
Mailing Address - Phone:904-396-5510
Mailing Address - Fax:904-396-5206
Practice Address - Street 1:4600 MIDDLETON PARK CIR E
Practice Address - Street 2:D-250
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5691
Practice Address - Country:US
Practice Address - Phone:800-423-1330
Practice Address - Fax:904-592-6575
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50118207R00000X
FLME102817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN697601800Medicaid
MN697601800Medicaid
MN110011409Medicare PIN