Provider Demographics
NPI:1295897155
Name:RISKEVICH, MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:RISKEVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 OCEAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3170
Mailing Address - Country:US
Mailing Address - Phone:718-934-8484
Mailing Address - Fax:718-934-4267
Practice Address - Street 1:2818 OCEAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3170
Practice Address - Country:US
Practice Address - Phone:718-934-8484
Practice Address - Fax:718-934-4267
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01810360Medicaid
NY208815OtherLICENSE
NY05V002Medicare PIN
NYG67830Medicare UPIN