Provider Demographics
NPI:1942221957
Name:RISI, MARK G (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:RISI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-3162
Mailing Address - Country:US
Mailing Address - Phone:609-448-4353
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ROBBINSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08691-3162
Practice Address - Country:US
Practice Address - Phone:609-448-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMBO55355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5232902Medicaid
NJF32767Medicare UPIN
RI042175Medicare ID - Type Unspecified