Provider Demographics
NPI:1669527925
Name:RISTICH, MIODRAG (MD)
Entity type:Individual
Prefix:DR
First Name:MIODRAG
Middle Name:
Last Name:RISTICH
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 1:37 SUNRISE LN
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1631
Mailing Address - Country:US
Mailing Address - Phone:201-934-5513
Mailing Address - Fax:253-369-8654
Practice Address - Street 1:201 E 79TH ST
Practice Address - Street 2:SUITE 7J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0830
Practice Address - Country:US
Practice Address - Phone:212-737-6990
Practice Address - Fax:212-988-3103
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1110752084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY111075OtherHIP
NYP518630OtherOXFORD
NY00198843Medicaid
NY31O281OtherEMPIRE BLUE CROSS BLUE SH
NY31O281OtherEMPIRE BLUE CROSS BLUE SH
NY31O281Medicare ID - Type Unspecified