Provider Demographics
NPI:1932189115
Name:TRAVISANO, VINCENT LOUIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:LOUIS
Last Name:TRAVISANO
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 1:7509 BIG BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2103
Mailing Address - Country:US
Mailing Address - Phone:314-961-3113
Mailing Address - Fax:314-968-7529
Practice Address - Street 1:7509 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2103
Practice Address - Country:US
Practice Address - Phone:314-961-3113
Practice Address - Fax:314-968-7529
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-22
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000459213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO301841607Medicaid
MO000021145Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MO301841607Medicaid
MO6754120001Medicare NSC