Provider Demographics
NPI:1497175863
Name:FULLER, RISA NAOMI (MD)
Entity Type:Individual
Prefix:
First Name:RISA
Middle Name:NAOMI
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RISA
Other - Middle Name:NAOMI
Other - Last Name:VECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 E 42ND ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-5699
Mailing Address - Country:US
Mailing Address - Phone:646-605-8186
Mailing Address - Fax:
Practice Address - Street 1:17 E 102ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291562-1207RI0200X
PAMT205745390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program