Provider Demographics
NPI:1922139559
Name:PAUL C KRISA, M.D, PA
Entity Type:Organization
Organization Name:PAUL C KRISA, M.D, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KRISA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-471-8850
Mailing Address - Street 1:1135 BROAD ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3346
Mailing Address - Country:US
Mailing Address - Phone:973-471-8850
Mailing Address - Fax:973-471-5232
Practice Address - Street 1:1135 BROAD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3346
Practice Address - Country:US
Practice Address - Phone:973-471-8850
Practice Address - Fax:973-471-5232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ42876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3290701Medicaid
NJ1588608525OtherNPI
NJC56594Medicare UPIN
NJ3290701Medicaid