Provider Demographics
NPI:1609875442
Name:NISSEN, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:NISSEN
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 1:240 E 82ND ST
Mailing Address - Street 2:APT. 6J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-2703
Mailing Address - Country:US
Mailing Address - Phone:212-772-7000
Mailing Address - Fax:
Practice Address - Street 1:1317 3RD AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2995
Practice Address - Country:US
Practice Address - Phone:212-772-7000
Practice Address - Fax:212-772-7001
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188503207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161012OtherELDERPLAN
NY434294POtherHIP
NY134174737OtherEMPIRE BLUE CR/BLUE SH
NY46350COtherMAGNACARE
NY0401390OtherGHI
NY134174737OtherMULTIPALN
NYP865763OtherOXFORD
NY134174737OtherGUARDIAN PHCS
NY134174737Other1199 BENEFIT FUND
NY2448242OtherAETNA USHEALTHCARE
NY01755637Medicaid
NY134174737OtherUNITED HEALTHCARE
NY188503B34OtherHEALTH FIRST
NY4987173005OtherCIGNA
NY134174737OtherSTOREWORKERS SECURITY PL
NY46350COtherMAGNACARE