Provider Demographics
NPI:1831275569
Name:FISSE, RICHARD DAVID (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:FISSE
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 1:1353 49TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1353 49TH STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-854-8527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134693207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
27802M622454780OtherHORIZON
17802OtherHORIZON MULTIPLAN
NYKS738OtherOXFORD
0014442OtherAETNA
000182501OtherMAGNACARE
000182501OtherAMERICHOICE OF NY
NY00699752Medicaid
NYB78797OtherHJP
27802M622454780OtherHORIZON
NYB78797OtherHJP