Provider Demographics
NPI:1043578495
Name:HRISOMALOS, EMILY N (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:N
Last Name:HRISOMALOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 W OAK ST STE 107
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-3835
Mailing Address - Country:US
Mailing Address - Phone:317-721-4190
Mailing Address - Fax:
Practice Address - Street 1:1650 W OAK ST STE 107
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-3835
Practice Address - Country:US
Practice Address - Phone:317-721-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132004207Y00000X
FL132004207Y00000X
IN01079923A207YS0123X, 207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01079923AOtherSTATE LICENSE