Provider Demographics
NPI:1780676023
Name:TISHKOFF, NEIL W (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:W
Last Name:TISHKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CEDAR ST STE TE2
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3206
Mailing Address - Country:US
Mailing Address - Phone:203-785-3067
Mailing Address - Fax:203-200-5170
Practice Address - Street 1:333 CEDAR ST STE TE2
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-3067
Practice Address - Fax:203-200-5170
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT377442085N0700X
CT0377442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001377440Medicaid