Provider Demographics
NPI:1306830047
Name:RISAM, MANJIT KAUR (MD)
Entity Type:Individual
Prefix:
First Name:MANJIT
Middle Name:KAUR
Last Name:RISAM
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 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:
Practice Address - Street 1:3060 MITCHELLVILLE RD
Practice Address - Street 2:210
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1389
Practice Address - Country:US
Practice Address - Phone:301-249-4090
Practice Address - Fax:301-390-1344
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032735207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA203249OtherHEALTHKEEPERS ID#
MD27866OtherJOHN HOPKINS EHP ID #
MD41985902OtherCAREFIRST MD ID #
DC56760001OtherCAREFIRST DC
46565OtherMAMSI ID#
495982OtherNCPPO ID #
04830OtherAMERIGROUP ID#
MD405671000Medicaid
4089037OtherAETNA PROVIDER #
0700031OtherUNITEDHEALTHCARE ID #
MD521854007OtherALL OTHER INS CO. ID #
160059456Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MD27866OtherJOHN HOPKINS EHP ID #
VA203249OtherHEALTHKEEPERS ID#