Provider Demographics
NPI:1760412167
Name:WISSMAN, ROBERT DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:WISSMAN
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 1:5400 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-2664
Mailing Address - Country:US
Mailing Address - Phone:513-281-3400
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2663
Practice Address - Fax:573-884-4608
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-31062085R0202X
MO20190335142085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426726Medicaid
OH2426726Medicaid
G37668Medicare UPIN
OHWI4115212Medicare PIN