Provider Demographics
NPI:1891792958
Name:FELDMAN, AVA RISA (DO)
Entity Type:Individual
Prefix:DR
First Name:AVA
Middle Name:RISA
Last Name:FELDMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9034
Mailing Address - Fax:920-663-0370
Practice Address - Street 1:12327 STRATFORD DR
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8148
Practice Address - Country:US
Practice Address - Phone:515-224-7088
Practice Address - Fax:515-224-9228
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02136207ND0900X, 207N00000X, 207ND0101X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2298364Medicaid
IA070007615OtherMEDICARE RAILROAD
IA070007615OtherMEDICARE RAILROAD
IA50507Medicare ID - Type Unspecified