Provider Demographics
NPI:1720630569
Name:VISEN, SRISHTI SINGH (MD)
Entity Type:Individual
Prefix:
First Name:SRISHTI
Middle Name:SINGH
Last Name:VISEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKDALE PLZ
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-3139
Mailing Address - Country:US
Mailing Address - Phone:718-240-5000
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2023-1134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program