Provider Demographics
NPI:1245346790
Name:KRISSOFF, WILLIAM B (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:B
Last Name:KRISSOFF
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 1:10051 LAKE AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4825
Mailing Address - Country:US
Mailing Address - Phone:530-582-0202
Mailing Address - Fax:530-582-0206
Practice Address - Street 1:10051 LAKE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4825
Practice Address - Country:US
Practice Address - Phone:530-582-0202
Practice Address - Fax:530-582-0206
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26823204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43108Medicare UPIN