Provider Demographics
NPI:1295711968
Name:RICCIARDI, COSIMO A (DPM)
Entity type:Individual
Prefix:DR
First Name:COSIMO
Middle Name:A
Last Name:RICCIARDI
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E REDSTONE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5370
Mailing Address - Country:US
Mailing Address - Phone:850-862-4119
Mailing Address - Fax:850-862-5470
Practice Address - Street 1:341A RACETRACK RD NW STE A
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1552
Practice Address - Country:US
Practice Address - Phone:850-862-4119
Practice Address - Fax:850-862-5470
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2964213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340234700Medicaid
FLCN7984OtherRAILROAD MEDICARE PALMETTO GBA
FL5663950001Medicare NSC
FL340234700Medicaid
FL5663950002Medicare NSC
FL65734YMedicare PIN