Provider Demographics
NPI:1376645911
Name:RISSMAN, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:RISSMAN
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 1:404 ZENA ROAD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-2626
Mailing Address - Country:US
Mailing Address - Phone:845-679-5271
Mailing Address - Fax:845-679-3237
Practice Address - Street 1:404 ZENA ROAD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2626
Practice Address - Country:US
Practice Address - Phone:845-679-5271
Practice Address - Fax:845-679-3237
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00728056Medicaid
NYB14951Medicare UPIN
46A691Medicare ID - Type Unspecified