Provider Demographics
NPI:1275571622
Name:RISMONDO, VIVIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:RISMONDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:RISMONDO-STANKOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 418953
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6569 N CHARLES ST
Practice Address - Street 2:STE 505
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6831
Practice Address - Country:US
Practice Address - Phone:443-849-8084
Practice Address - Fax:443-849-6817
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43499207W00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKJ54GB/53000103OtherCAREFIRST MARYLAND GBMC
MDS1410003OtherCAREFIRST REGIONAL GBMC
MD762851000Medicaid
MD714L030YMedicare PIN
MDS1410003OtherCAREFIRST REGIONAL GBMC
MDKJ54GB/53000103OtherCAREFIRST MARYLAND GBMC
MD180035563Medicare PIN