Provider Demographics
NPI:1891780904
Name:RISSMAN, LAWRENCE JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JEFFREY
Last Name:RISSMAN
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 1:1212 PLEASANT ST STE LL3
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1414
Mailing Address - Country:US
Mailing Address - Phone:515-241-8861
Mailing Address - Fax:515-241-8855
Practice Address - Street 1:1212 PLEASANT ST STE LL3
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1414
Practice Address - Country:US
Practice Address - Phone:515-241-8861
Practice Address - Fax:515-241-8855
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21307207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6107151Medicaid
IAD25571Medicare UPIN
IAI12200*Medicare ID - Type Unspecified