Provider Demographics
NPI:1790789493
Name:NISENBAUM, JOSEF (DO)
Entity Type:Individual
Prefix:
First Name:JOSEF
Middle Name:
Last Name:NISENBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 DIAMOND TAIL RD
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-8338
Mailing Address - Country:US
Mailing Address - Phone:505-264-3550
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:126 DIAMOND TAIL RD
Practice Address - Street 2:
Practice Address - City:PLACITAS
Practice Address - State:NM
Practice Address - Zip Code:87043-8338
Practice Address - Country:US
Practice Address - Phone:505-264-3550
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1195-022085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31201059Medicaid
343411101Medicare PIN
F26137Medicare UPIN
NM347233901Medicare PIN