Provider Demographics
NPI:1770088957
Name:RISOVAS, JON JORGE
Entity type:Individual
Prefix:
First Name:JON
Middle Name:JORGE
Last Name:RISOVAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-4422
Mailing Address - Country:US
Mailing Address - Phone:386-310-3529
Mailing Address - Fax:386-310-2106
Practice Address - Street 1:1530 CORNERSTONE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7129
Practice Address - Country:US
Practice Address - Phone:386-310-3529
Practice Address - Fax:386-310-2106
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-28
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME146328207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty