Provider Demographics
NPI:1922004654
Name:KRISO, STEPHEN ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:KRISO
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 1:44 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-1219
Mailing Address - Country:US
Mailing Address - Phone:973-779-3030
Mailing Address - Fax:973-779-0225
Practice Address - Street 1:44 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WALLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07057-1219
Practice Address - Country:US
Practice Address - Phone:973-779-3030
Practice Address - Fax:973-779-0225
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA00021589207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2732700Medicaid
458786Medicare ID - Type Unspecified
NJ458786Medicare PIN
NJ2732700Medicaid