Provider Demographics
NPI:1386638021
Name:RISAM, RANJIT S (MD)
Entity Type:Individual
Prefix:
First Name:RANJIT
Middle Name:S
Last Name:RISAM
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 1:3060 MITCHELLVILLE RD
Mailing Address - Street 2:210
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1389
Mailing Address - Country:US
Mailing Address - Phone:301-249-4090
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:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0032769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100010OtherUNITEDHEALTHCARE ID
497053OtherNCPPO ID
MD41986001OtherCAREFIRST MD
DC42350001OtherCAREFIRST DC
819810OtherMAMSI PRODUCTS ID
VA203250OtherHEALTHKEEPERS
5056288OtherAETNA ID
DC42350001OtherCAREFIRST DC
MD41986001OtherCAREFIRST MD
B94403Medicare UPIN