Provider Demographics
NPI:1194042820
Name:RISMA, JUSTIN M (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:RISMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2140 JFK RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-3883
Mailing Address - Country:US
Mailing Address - Phone:563-582-0769
Mailing Address - Fax:563-582-5772
Practice Address - Street 1:2140 JFK RD
Practice Address - Street 2:SUITE F
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-3883
Practice Address - Country:US
Practice Address - Phone:563-582-0769
Practice Address - Fax:563-582-5772
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA41585207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0201517Medicaid
IA0201517Medicaid