Provider Demographics
NPI:1376030239
Name:RISMAN, ELIJAH RAY (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIJAH
Middle Name:RAY
Last Name:RISMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 N DAMEN AVE UNIT 308
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6917
Mailing Address - Country:US
Mailing Address - Phone:480-320-8882
Mailing Address - Fax:
Practice Address - Street 1:2157 N DAMEN AVE UNIT 308
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6917
Practice Address - Country:US
Practice Address - Phone:480-320-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist