Provider Demographics
NPI:1720089006
Name:NISI, RUDOLPH H (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:H
Last Name:NISI
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 1:2475 SAINT RAYMONDS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3124
Mailing Address - Country:US
Mailing Address - Phone:718-824-8693
Mailing Address - Fax:718-892-7427
Practice Address - Street 1:2475 SAINT RAYMONDS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3124
Practice Address - Country:US
Practice Address - Phone:718-824-8693
Practice Address - Fax:718-892-7427
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085499-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D46696Medicare UPIN
891923Medicare ID - Type Unspecified