Provider Demographics
NPI:1174929442
Name:DENENBURG, ROSTISLAV (DPM)
Entity type:Individual
Prefix:
First Name:ROSTISLAV
Middle Name:
Last Name:DENENBURG
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 1:4881 NW 8TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-416-1082
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:4343 W NEWBERRY RD
Practice Address - Street 2:SUITE 7
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2824
Practice Address - Country:US
Practice Address - Phone:352-331-3077
Practice Address - Fax:352-331-3265
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003898213E00000X
FLPO4431213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115116100Medicaid