Provider Demographics
NPI:1518691658
Name:KISAMORI, EIRI (MD)
Entity Type:Individual
Prefix:
First Name:EIRI
Middle Name:
Last Name:KISAMORI
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 1:111 MICHIGAN AVE NW STE 400500
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2916
Mailing Address - Country:US
Mailing Address - Phone:202-476-3597
Mailing Address - Fax:
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-305-5975
Practice Address - Fax:212-305-4408
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMTL600001542208G00000X
NY328887208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)