Basic Information
| Provider Information | |||||||||
| NPI: | 1033559612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGGOW | ||||||||
| FirstName: | BRIELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 THE RIALTO | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342853524 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 712 THE RIALTO | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342853524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414880222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO3772 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | PO3772 | 01 | FL | STATE LICENSE | OTHER |