Provider Demographics
NPI:1225349715
Name:RAISSIAN, TIMOTHY AMIN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:AMIN
Last Name:RAISSIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 E GLENROSA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4324
Mailing Address - Country:US
Mailing Address - Phone:615-497-2523
Mailing Address - Fax:
Practice Address - Street 1:1955 W FRYE RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6282
Practice Address - Country:US
Practice Address - Phone:480-728-3753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72043390200000X
AS46595207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program