Provider Demographics
NPI:1689170540
Name:RIESGO, VINCENT JAMES (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:JAMES
Last Name:RIESGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY VENUE ROOM 202 MAIN HOSPITAL MSC333
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5054
Practice Address - Country:US
Practice Address - Phone:786-348-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149767207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program