Basic Information
Provider Information
NPI: 1033559612
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROGGOW
FirstName: BRIELLE
MiddleName: LYNN
NamePrefix: DR.
NameSuffix:  
Credential: D.P.M.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 712 THE RIALTO
Address2:  
City: VENICE
State: FL
PostalCode: 342853524
CountryCode: US
TelephoneNumber:  
FaxNumber:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213E00000XPO3772FLY Podiatric Medicine & Surgery Service ProvidersPodiatrist 

ID Information
IDTypeStateIssuerDescription
PO377201FLSTATE LICENSEOTHER


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