Provider Demographics
NPI:1457309619
Name:RISER, MARK RANDOLPH (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RANDOLPH
Last Name:RISER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-4610
Mailing Address - Country:US
Mailing Address - Phone:973-740-0607
Mailing Address - Fax:
Practice Address - Street 1:3 CENTURY DR
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-4610
Practice Address - Country:US
Practice Address - Phone:973-740-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900332207P00000X, 207Q00000X
NY268189-1207Q00000X, 207P00000X
RI13867207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G58084Medicare UPIN