Provider Demographics
NPI:1669479010
Name:NISSAN, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:NISSAN
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 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1790
Mailing Address - Country:US
Mailing Address - Phone:631-261-4445
Mailing Address - Fax:631-261-3710
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1790
Practice Address - Country:US
Practice Address - Phone:631-261-4445
Practice Address - Fax:631-261-3710
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00590001Medicaid
NY24A921OtherMEDICARE LEGACY
1C2496OtherHEALTHNET
0520035OtherAETNA
NY442081060OtherMEDICARE RAILROAD PTAN
CP521OtherOXFORD
0065892OtherGHI
NY24A921OtherBLUE CROSS BLUE SHIELD
10263OtherVYTRA
CP521OtherOXFORD
10263OtherVYTRA