Provider Demographics
NPI:1528190972
Name:RISSER, FRED D (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:D
Last Name:RISSER
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 1:44 SILVER RDG
Mailing Address - Street 2:
Mailing Address - City:VEAZIE
Mailing Address - State:ME
Mailing Address - Zip Code:04401-7084
Mailing Address - Country:US
Mailing Address - Phone:207-947-0366
Mailing Address - Fax:
Practice Address - Street 1:42 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6433
Practice Address - Country:US
Practice Address - Phone:207-947-0366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0146522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME234980099Medicaid
ME260047956OtherRAILROAD MEDICARE
ME234980099Medicaid
ME260047956OtherRAILROAD MEDICARE