Basic Information
| Provider Information | |||||||||
| NPI: | 1861816860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRASOL | ||||||||
| FirstName: | VANESSA | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 356 GINGER DR BOX 7414 | ||||||||
| Address2: | |||||||||
| City: | DIBERVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395409081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2287601235 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 VETERANS AVE | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285235000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2014 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | P205 | HI | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.